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V <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 <br /> R (tw,pages per tank) <br /> Page al <br /> TYPE OF ACTION ❑1,NEW SITE PERMIT Cl 4. AMENDED PERMIT Cl 5. CHANGE OF INFORMATION) ❑ S. TEMPORARY SITE CLOSURE <br /> (Check one item only) ❑ T. PERMANENTLY CLOSED ON SITE <br /> ❑3.RENEWAL PERMIT (Sp Poyneonn-AVlocalmeonly) (Spedry Mange-torl.ew Dory) ❑ 8. TANK REMOVED 43D <br /> BUSINESS NAME(Same M FACWTY NAME Pr DSA-Doug Susswas As) FACIUTY ID k 1 <br /> LOCATION WTHM SITE(0000, ) <br /> 1 F tb tI Z za <br /> I.TANK.DESCRIPTION <br /> TANK 109TANK MANUFACTURER COMPARTMENTALIZED TANK ❑ Yea ❑ Np <br /> 160601 <br /> it'Yes".complete we Page for som compartment. <br /> DATE INSTALLEO(YEAR/MO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> AODMONAL DESCRIPTION(Forlocal ase a*) <br /> IL TANK CONTENTS <br /> TANK USE 432 PETROLEUM TYPE <br /> ❑ 1. MOTOR VEHICLE FUEL 111. REGULAR UNLEADED ❑ 2. LEADED ❑ S. JETFUEL <br /> (pmahad,..&m Peepleom Typo) ❑10. PREMIUM UNLEADED ❑ 3. DIESEL ❑ 5. AVIATIONFUEL <br /> ❑ 2. NON-FUELPETROLEUM ❑it, MIOGRADE UNLEADED ❑ 4. GASOHOL ❑%. OTHER <br /> ❑ 3. CHEMICAL PRODUCT <br /> COMMON NAME Omn,Hazardous Mctsriels Imenfmypege) GSM(Isom Hazardous Afatenela Imenf sypage) <br /> ❑ 4. HAZARDOUS WABTE(IrICIWea <br /> 0 95 <br /> Used Dip <br /> lm <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1. SINGLEWALL ❑ 3. SINGIFWALLVATH Cl 5. SINGLEWALL`MTHINTERNALSLADDERSYSTEM <br /> (Chock",to.o*) Cl 2 DOUSLEWALL EXTERIOR MEMBRANE LINER 095. UNKNOWN <br /> ❑ 4. SINGLE WALL IN A VAULT ❑ss OTHER <br /> TANK MATERIAL-primary tank Cl 1 BARE STEEL ❑ 3. FIBERGLASS I PLASTIC Cl 5. CONCRETE 095. UNKNOWN <br /> (Chock one item only) ❑ L STAINLESS STEEL ❑ 4. STEEL CLAD WIFIBERGLASS ❑ S. FRPCOMPATIBLEWIT00%METHANOL 099. OTHER <br /> REINFORCED PLASTIC IMP) <br /> TANK MATERIAL-sacoMary bnk ❑ I BARE STEEL ❑ 1 FlBERGIASSIPI-ASTIC ❑ B. FRP COMPATIBLE W IW%METHANOL 095. UNKNOWN <br /> (Check one item only) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAO WIFIBERGIASS Cl 9. FRP NOMCORRODIBLE JACKET ❑99. OTHER <br /> REINFORCED PLASTIC FRP) 1310. COATED STEEL <br /> ❑ 5. CONCRETE <br /> TANK INTERIOR LINING Cl 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ S. GLASS LINING ❑95. UNKMOWN433 DATE INSTALLED <br /> OR COATING <br /> Cl 2. ALKYD LINING 134. PHENOLIC LINING ❑ 8. UNIJNED ❑99. OTHER <br /> CMck Dna item only) (FPrlpcal use.1y) <br /> OTHER CORROSION Cl 1. MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC Cl 95. UNKNOWN 434 DATE INSTALLED <br /> PROTECTION IF APPLICABLE PROTECTION <br /> ❑ 4. IMPRESSED CURRENT ❑99. OTHER <br /> (Chock orte item Doty) ❑ 2. SACRIFICIALANODE (ForlxeluaaMq- <br /> SPILLAND OVERFILL YEARINSTALLED TYPE(FPllocala.PPly) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (Chock all that aptly) ❑ 1. SPILLCONTAINMENT ❑ 1. ALARM ❑ 3. FILL TUBE SHUTOFF VALVE <br /> ❑ 2. DROP TUBE ❑ 2. BALL FLOAT ❑ 4. EXEMPT <br /> ❑ 3. STRIKER PLATE <br /> IV. TANK LEAK DETECTION <br /> IF SINGLE WALL TANK(Check all that 3PW t IF DOUBLE WALL TANK OR TANK WITH BLADDER(Chenk one item anryl: <br /> ❑ 1. VISUAL(EXPOSED PORTION ONLY) ❑ S. MANUAL TANK GAUGING(MM) ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(AM) ❑ S. VADOSE ZONE ❑ 2. CONTNUOUSINTERSTTIALMONITORING <br /> ❑ 3. CONTINUOUSATG ❑ T. GROUNDWATER ❑ 3. MANUAL MONITORING <br /> ❑ 4. STATISTICAL INVENTORY RECONCIUATION(SIR) ❑ S. TANK TESTING <br /> BIENNIAL TANK TESTING ❑99. OTHER <br /> V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED GATE LAST USED(YRIMOIOAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 415 TANKFILLED VATHINERTMATERIAL] <br /> �H 99 9e9ona ❑Yu No <br /> CUPAFORM(4199) Formerly SWRCB Fon B <br />