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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 <br /> (faro pages per tank) <br /> Pella _ W <br /> i <br /> TYPE OF ACTION 01.NEW SITE PERMIT ❑ a. AMENDED PERMIT ❑ S. CHANGE OF INFORMATION) 0 S. TEMPoRARV SITE CLOSURE <br /> } (Check one item oMy) ❑ T PERMANENTLY CLOSED ON SITE <br /> ❑3.RENEWAL PERMIT (Speayreason-Iwlocal use aUy) (Speay,cMrpe-br local use only) ❑ & TANK REMOVED AM <br /> BUSINESS NAME(Same as FACILITY NAME or OBA-Dan9 Business Aa) FACILITY ID 9 <br /> I <br /> LOCATION WITHIN SITE(OMlonaq 631 <br /> Z� L Z�J <br /> 1.TANK DESCRIPTION <br /> TANK 109TANK MANUFACTURER COMPARTMENTAUZED TANK ❑ Yea ❑ No <br /> 60 I <br /> V 0 n' mmgale o M PN;a a each compamnent <br /> DATE INSTA D(YEAR/MO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> ADDITIONAL DESCRIPTION(Forloul use aHyl <br /> IL TANK CONTENTS <br /> TANK USE 432 PETROLEUM TYPE <br /> ❑ 1. MOTOR VEHICLE FUEL ❑N, REGULAR UNLEADED ❑ Z LEADED ❑ 5. JET FUEL <br /> (IrmaMeV.rompNN PolmMom Type) ❑1b. PREMIUM UNLEADED ❑ 3. DIESEL ❑ 6 AVIATION FUEL <br /> ❑ 2. NON-FUEL PETROLEUM ❑tc MIDGRADE UNLEADED ❑ a. GASOHOL ❑9B. OTHER <br /> ❑ 3.CHEMICAL PRODUCT <br /> COMMON NAME f1loNn HAralEans Materiels InaaMorypepel CAS C(ham MazaNpua MebnNS Tmenbrypagel <br /> ❑ a. HAIARDQN$WASTE(IwJWaa <br /> uaN an <br /> rl 95 UNKNOWN <br /> 10.TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1 SINGLE WALL ❑ 1 SINGLE WALL WITH ❑ S. SINGLE WALL WTH INTERNAL BLADDER SYSTEM <br /> (Check ane Rem ony) ❑ 2. DOUBLE WALL EXTERIOR MEMBRANE UNER 095. UNKNOWN <br /> ❑ 4. SINGLE WALL INA VAULT ❑rya OTHER <br /> TANK MATERIAL-primary tank ❑ 1 BARE STEEL ❑ 3. FIBERGLASS I PUSTIC ❑ 5, CONCRETE C3 95. UNKNOWN <br /> fcM ,neilemonly) ❑ 2, STAINLESS STEEL ❑ 6. STEEL CUD W/FIBERGLASS ❑ 8, FRP COMPATIBLE WI1W%METHANOL 099. OTHER <br /> REINFORCED PLASTIC(FRPI <br /> TANK MATERIAL-secontlary tank ❑ 1 BARE STEEL ❑ 3. FIBERGLASS I PUSOC ❑ B. FRP COMPATIBLE W/190%METHANOL 095, UNKNOWN <br /> (Chxkwmifem Pnly) ❑ 2, STAINLESS STEEL ❑ a. STEEL CUD WIFISERGUSS ❑ 9. FRP NONLORRODIBLE JACKET 099. OTHER <br /> REINFORCED PUSTIC(FRPI 010 COATED STEEL <br /> ❑ 5. CONCRETE <br /> TANK INTERIOR UNING ❑ L RUBBER UNED ❑ 3. EPDXY UNING ❑ & GLASS LINING 095, UNKNOWNAG DATEINSTALLED <br /> OR COATING <br /> ❑ 2.ALKYD IJNING ❑ 6. PHENOLIC LINING ❑ B. UNLINED 099. OTHER WbcM use oMY) <br /> (Check one Hem onl) <br /> OTHER CORROSION ❑ 1. MANUFACTUREOCATHODIO ❑ 3. FIBERGLASS REINFORCED PLASTIC 0 9 UNKNOWN a3a GATE INSTAlJF11 <br /> PROTECTIONIF APPUCASLE PROTECTION <br /> ❑ a. IMPRESSED CURRENT 099. OTHER (Forbsa/uaa oMyq <br /> (Check Pne iMn.ry) ❑ 2 SACRIFICIAL ANODE <br /> SPILL AND OVERFILL YEAR INSTALLED TYPE(Fprlaael use oMy) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (Check aY That appy) ❑ 1. SPUCONTAINMENT ❑ 1. ALARM ❑ 3. FILL TUBE SHUT OFF VALVE <br /> ❑ Z DROPTUBE ❑ 2. BALL FLOAT ❑ a. EXEMPT <br /> ❑ 3. STRIKER PLATE <br /> IV. TANK LEAK DETECTION <br /> IF SINGLE WALL TANK CNall all that apply): IIF DOUBLE WALL TANK OR T/WK WITH BUDDER(Chock ore NIM OW: <br /> ❑ 1, VISUAL(EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ S. VADOSEZONE ❑ 2. CONTINUOUS INTERSTITIAL MONITORING <br /> ❑ 3. CONTINUOUSATG ❑ T. GROUNDWATER ❑ 3. MANUALMONITORING <br /> ❑ A STATISTICAL INVENTORY RECONCILIATION(SIR) ❑ S. TANKTESTING <br /> BIENNIAL TANK TESTING 099. OTHER <br /> V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE UST US D(YRMO/OAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING a35 TANK FILLED WITH INERT MATERIAL? <br /> 8XM9 ❑YBa ❑ <br /> CUPAFORM(4/99) Formedy SWRCB Form S <br />