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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 1 (two pages per tank) Page�of L TYPE OF ACTION ❑1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (check ow ion only) ❑ 7 PERMANENTLY CLOSED ON SITE 3 RENEWAL PERMIT (Speclfymasw-forlawlaseonly) (Specifyteeson-mrlocaluseoely) ❑ 8 TANK REMOVED 430 FACILITY ID: 1 BUSINESS NAME(Sameaz FACILITY NAME or DBA-Doivg Business Ae) 3 S017 Us 4 6ytr�.Q T✓ 4f LOCATION W IN SITE(opnoom) 431 I.TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local agency.) TANK ID# 633 TANK MANUFACTURER 013 COMPARTMENTALIZED TANK ❑Yes 0 4M -TAw's-li,� D��S 4bentz "Y .wmPlHeoMpBe fm ehwmpah wt. DATE INSTAL ED(YEAR/MO) 015 TANK CAPACITY IN GALLO 436 NUMBER OF COMPARTMENTS 437 �� qZ 6 000 z�C NA ADDITIONAL DESCRIPTION(For Iwd nee only) 638 11.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 610 ❑L MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (Ifnuaedwmplote Pet,olwm Type) ❑lb. PREMIUM UNLEADED 03. DIESEL ❑6. AVIATION FUEL- ' ❑2. NON-FUEL PETROLEUM ❑le. MIDGRADE UNLEADED ❑4. GASOHOL �99.OTHER UJPj on L 03. CHEMICAL PRODUCT COMMON NAME (Som H.&.hfaleriol4 Inventory page) 661 CAS#(Som H-Mous Materiels Inventory lege)/ 463 >al4. HAZARDOUSWASTE DI -6- 900z (locludw Used Oib S VL ❑95.UNKNOWN III. TANK CONSTRUCTION TYPE OF TANK L SINGLE WALL 3. SINGLE WALL WITH 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one,item only) EXTERIOR MEMBRANE LINER 095. UNKNOWN ffi(2. DOUBLE WALL ❑4. SIGNLE WALL IN VAULT ❑99. OTHER TANK MATERIAL 1. BARE STEEL JK3. FIBERGLASS/PLASTIC 5. CONCRETE 0 95. UNKNOWN 444 (check a=neen only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FBIERGLASS ❑8. FRP COMPTIBLE W/100%,METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL----.Mary rank 1. BARESTEEL R5,1. FIBERGLASS/PLASTIC 0 5. CONCRETE 0 95. UNKNOWN 445 (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FB3ERGLASS ❑8. FRP COMPTIBLE W/100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10.COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING OLRUMBERLINED L1 3.EPDXY LINING CL5.GLASS LINING 0 95.UNKNOWN 446 DATE INSTALLED 447 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING ❑6 UNLINED ❑99 OTHER (Check one item only) (Far heal use only) OTHER CORROSION ❑l MANUFACTURED CATHODIC JS3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN 448 DATE INSTALLED 449 PROTECTION IF APPLICABLE PROTECTION ❑4IMPRESSED CURRENT ❑99 OTHER (Check mit item only) ❑2 SACRIFICIAL ANODE (For Wcal one,only) SPILL AND OVERFILL YEAR INSTALLED 450 TYPE(local use only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (C'IwckaOthotvply) 5(1 SPILL CONTAINMENT 0 ALARM s❑sy�.g3 FILL TUBE SHUT OFF VALVE E]2 DROP TUBE ❑2 BALL FLOAT q4 EXEMPT [R3 STRIKER PLATE IV.TANK LEAK DETECTION(A description of the monitoring program Shull be submittrA to the local agency.) IF SINGLE WALL TANK(cheek all aatapply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 (check one nem only) ❑1 VISUAL('EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MTG) ❑1 VISUAL(SINGLE WALL IN VAULT ONLY) ❑2 AUTOMATIC TANK GAUGING(ATG) ❑6 VADOSE ZONE K2 CONTINUOUS INTERSTITIAL MONITORING ❑3 CONTINUOUS ATG ❑7 GROUNDWATER ❑3 MANUAL MONITORING ❑4 STATISTICAL INVENTORY RECONCILIATION ❑8 TANK TESTING (SIR) BIENNIAL TANK TESTING ❑99 OTHER IV.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 656 TANK FILLED WITH INERT MATERIA,? 457 gallons ❑Yes ❑ No UPCF(12/99 revised) 10 Formerly SWRCB Form B