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3 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 1 <br /> (Iwo pages per lank) <br /> Page _ of <br /> TYPE OF ACTION 01.NEW SITE PERMIT 0 4. AMENDED PERMIT )�5. CHANGE OF INFORMATION) D B.TEMPORARY SITE CLOSURE <br /> (Check orw Bem Dray) 0 i. PERMANENTLY CLOSED ON SITE <br /> 03.RENEWAL PERMIT (Splay mason-(or /uae oMy) (Spea/yamn,s-turlocelusaony) D B.TANK REMOVED 430 <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Bmirwes As) FACILYTY IDA 1 <br /> ib <br /> LOCATION WITHIN SITE(Op#MO 431 _ <br /> TANK DESCRIPTION <br /> TANKID# TANK MANUFACTURER COMPARTMENTALIZED TANK ❑ Vea No <br /> _7 Q�,���� if'Yee,complete one papa fineaoh mmpaNnent. <br /> DATE INWALLED(YEARIMO) TANK CAPACITY IN WLLON3 NUMBER OF COMPARTMENTS <br /> ADDITIONAL DESCRIPTION(Formcal use omy). <br /> II.TANK CONTENTS <br /> ....,,,,,,,,(((( TANK USE 432 PETROLEUM TYPE <br /> ,IT MOTOR VEHICLE FUEL REGULAR UNLEADED TO Z LEADED ❑ 5. JET FUEL <br /> #marked,complete Patmbum Type) ❑lb. PREMIUM.UNLEADED 3. DIESEL8. AVIATION FUEL <br /> 2. NON-FUEL PETROLEUM ❑1c MIDGRADE UNLEADED 4. GASOHOL <br /> 094 OTHER <br /> ❑ 3.CHEMICAL PRODUCT COMMON NAME(Imm Nazardam Mafedalx/nwnlorypage) CAS#(Pmm Hazallous Matelots lmenmrypage) <br /> ❑ 4. HAZARDOUS WASTE Onal�- <br /> U-ed Oq <br /> Fl 95 LINKNOWN <br /> In.TANK CONSTRUCTION <br /> TYPEOF TANK ❑ 1. SINGLEWALL 03. SINGLEWALLWTH 0 5.SINGLE WALL NTH INTERNAL BUDDER SYSTEM <br /> ,,....,,// EXTERIOR MEMBRANE LINER 095. UNKNOWN <br /> (Check mte dem oMy) pQ 2. DOUBLE WALL 04. SINGLE WALL IN A VAULT <br /> � <br /> ❑N.OTHER <br /> TANK MATERIAL-pNoery tank 0 1. BARE STEEL IOa 3. FIBERGLASS/PLASTIC 05. CONCRETE 085. UNKNOWN <br /> (Cme*one"M onw ❑ 2. STAINLESS STEEL 04. EEL CUD PLASTIC FRP D 8, FRP COMPATIBLE NlW%METHANOL 0W. OTHER <br /> REINFORCED <br /> TANK MATERIAL-aewndaq tank ❑ 1 BARE STEEL 0.4. FIBERGLASS/PLASTIC D 8. FRP COMPATIBLE NlW%METHANOL 095. UNKNOWN <br /> (Check am dee omy) 0 2. STAINLESS STEEL 0 4.N CUD WFIBERGLASS <br /> DPLAB'Tlc(FRP 0 9. FRP NON-CORRODIBLE JACKET _ 099. OTHER- <br /> REINFORCED <br /> THER <br /> 0 ID. COATED STEEL <br /> D 5. CONCRETE <br /> TANK INTERIOR LININGr DATE INSTALLED <br /> OR COATING ❑ 1. RUBBER LINED ❑ 3. EPDXY 11NING ❑r�5. CUSS LINING 085. UNKNOWN133 <br /> 0 2.ALKYD LINING D 4. PHENOLIC LINING MS. UNLINED 099. OTHER FP/IocnIm6 ) <br /> Checkonedemon ) DATEINSTALLED <br /> OTHER CORROSION D 1. MANUFACTURED CATHODIC D 3. FIBERGLASS REINFORCED PLASTIC 095. UNKNOWN 434 <br /> PROTECTION IF APPLICABLE PROTECTION <br /> ❑ 4. IMPRESSED CURRENT ❑99. OTHER (Forlocal use Dory) <br /> (CmokmwffemonW ❑ 2. SACRIFICIAL ANODE. <br /> SPILLANDOVERFILL - YEAR INSTALLED TYPE(Forloml use may) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (CMck an apply) 1. SPILL CONTAINMENT D 1.ALARM __ 3. FILL TUBE SHUT OFF VALVE <br /> OPTUBE D 2. BALL FLOAT ❑ 4. EXEMPT <br /> STRIKER PLATE <br /> IV.TANK'iEAK DETECTION <br /> Check all Mata IFDOUSLEWALLTANKORTANKTWIBLAODER(Chso .-Ill monly): <br /> IF SINGLE WALL TANK <br /> ❑ 1, VISUAL(EXPOSEDPORTION ONLY) 0 5. MANUAL TANK GAUGING(MTG) ❑.,/1,,trISUAL(SINGLE WALL IN VAULT ONLY). <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) 0 8. VAOOSEZONE I 1 CONTINUOUS INTERSTITIAL MONITORING <br /> 0 3. CONTINUOUSATG. 0 T. GROUNDWATER ❑ 3. MANUALMONITORING <br /> 0 4. STATISTICALINVENTORY RECONCILIATION(SIR) 0 8. TANKTESTING. <br /> BIENNIAL TANK TESTING 099. OTHER <br /> V.TANK CLOSURE INFORMATION I PERMANENTCLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YRIMO/DAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL? <br /> gallon. - D Yes ON. <br /> Formerly SWRCB FOrm S <br /> CUPAFORM(4/99) <br />