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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 1 (two pages per tank) Page_of_ TYPE OF ACTION ❑1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ b TEMPORARY SITE CLOSURE (Check one non only) ❑ 7 PERMANENTLY CLOSED ON SITE R 3 RENEWAL PERMIT (Speouymmon-thrla maonly) (Specify cogen-for local a se only) ❑ 8 TANK REMOVED 430 BUSINESS NAME(Same m FACILITY NAME or DOA-Doing BmWas Aa) FACILITY ID: l Trt _S LOCATI N W IN SITE( phonal) ail 1.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# 032 TANK•'MANUFACTURER 413 COMPARTMENTALIZED TANK ❑Yes No 434 +K7-7p bas?,3 4)4J�st �lJvn i Ya",cmnplete one,age for each c nnpeNnent. DATE INST LLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 1 NUMBER OF COMPARTMENTS 437 -5-1,19)111921 4 h/f ADDITIONAL DESCRIPTION(For local nae only) 438 IL TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 ❑1. MOTOR VEHICLE FUEL [Ila. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (Ifmakcd complete Petroleum Type) [I lb. PREMIUM UNLEADED 03. DIESEL ❑b. AVIATION FUEL Z2. NON-FUEL PETROLEUM ❑tc. MIDGRADE UNLEADED ❑4. GASOHOL JK99.OTHER /40ro- &L ❑3. CHEMICAL PRODUCT COMMON NAME (Goan Boannioue Matuiala fnvmmry page) 441 CAS#(from Hawdoos Matenals Inventory page) 442 ❑4. HAZARDOUS WASTE (InaladeaUSM Oil) kD far aIL 16--40W 04S 4k 64-7`E1 -d8-4/ ❑95.UNKNOWN HL TANK CONSTRUCTION TYPE OF TANK 1. SINGLE WALL 3. SINGLE WALL WITH 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Cheek one itnn only) EXTERIOR MEMBRANE LINER [3 95. UNKNOWN A2. DOUBLE WALL ❑4. SIGNLE WALL IN VAULT ❑99. OTHER TANK MATERIAL-prwmy tank 0 T.-BARE STEEL 3. FIBERGLASS/PLASTIC 5. CONCRETE 0 95. UNKNOWN 444 (Check one item only) ❑2. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPTIBLE W/100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-neeond ytank 1. BARE STEEL 2%3. FIBERGLASS/PLASTIC U 5. CONCRETE 95. UNKNOWN 445 (Check ane itnn only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPTIBLE W1100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) ❑]0.COATED STEEL ❑S. CONCRETE TANK INTERIOR LINING EILRUBBERLINED 0 3.EPDXY LINING 5.GLASS LINING C3 95.UNKNOWN 446 DATE INSTALLED 447 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING ❑b UNLINED ❑99 OTHER (Chale ane item only) (Fa local use only) OTHER CORROSION ❑I MANUFACTURED CATHODIC JK3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN 448 DATE INSTALLED 449 PROTECTION IF APPLICABLE PROTECTION ❑4IMPRESSED CURRENT ❑99 OTHER (Chale one ircsn only) ❑2 SACRIFICIAL ANODE (Fa I"as only) SPILL AND OVERFILL YEARINSTALLED 450 TYPE(laal one only) 451 OVERFILL PROTECTION EQUIPMENTNEAR INSTALLED ZOOZL 452 (Cherkallthatapply) 1f I SPILL CONTAINMENT ❑I ALARM NL3 FILL TUBE SHUT OFF VALVE Pj2 DROP TUBE ❑2 BALL FLOAT ❑4 EXEMPT Ig 3 STRIKER PLATE IV.TANK LEAK DETECTION(A description of one monitoring program altm he nuhmitmd a the local agency.) IF SINGLE WALL TANK(Chale all tom apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER a54 (Chock one item only) ❑1 VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MTG) ❑I VISUAL(SINGLE WALL IN VAULT ONLY) ❑2 AUTOMATIC TANK GAUGING(ATG) ❑b VADOSE ZONE W 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 956 TANK FILLED WITH INERT MATERIAL? 457 gallons ❑Yes ❑ No UPCF(12/99 revised) 10 Formerly SWRCB Form B