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6 „ 6 o3 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 <br /> (twn pages per tank) <br /> Page _ of <br /> TYPEOFACTION 01.NEW SITE PERMIT D 4.AMENDED PERMIT ❑ 5. CHANGE OF INFORMATION) 0 9. TEMPORARY SITE CLOSURE <br /> (Check one dem any) 0 T. PERMANENTLY CLOSED ON SITE <br /> 113.RENEWAL PERMIT (SpeaAy reason-hrbcM uaa oMy) (Spedychange-krloW OnW 0 B. TANK REMOVED 430 <br /> BUSINESS NAME(Same as FAClUTY NAME or DBA-Doing Business As) FACILITY ID I: 1 <br /> Z71e Na <br /> LOCATION WITHIN SITE(Optionep 431 _ <br /> Z <br /> 1.TANK D CRIPTION <br /> TANKIOe TANK MANUFACTURER COMPARTMENTALIZED TANK ❑ Yea Ev. <br /> IffO ,complete one page for each wmpedment <br /> EATEINSTALLED(YF WO) - - TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> ADDITIONAL DESCRIPTION MorPocal use pmy)- <br /> II.TANK CONTENTS <br /> Is� TANK USE 432 PETROLEUM TYPE <br /> W T.MOTOR VEHICLE FUEL 01a. REGULAR UNLEADED ❑ 2. LEADED ❑ S. JET FUEL <br /> (NmeAeq compNfe PatroNum Type) ❑tb. PREMIUM UNLEADED ❑ 3. DIESEL ❑ B.AVIATION FUEL <br /> 0 2. NON-FUEL PETROLEUM 91- MIDGRADEUNLEADED ❑ 4. GASOHOL ❑99. OTHER <br /> 0 3.CHEMICAL PRODUCT COMMON NAME(/mm Hazardous Matedala Inwfi rype90) CAS 0(dom Hama oc McM621S Inwnrorype98) <br /> 04. HAZARDOUS WASTE(IndWa- <br /> USedOA <br /> UNKNOWN <br /> III.TANKCONSTRUCTION <br /> TYPE OF TANK ❑ t SINGLE WALL 0 3. SINGLE WALL WITH 0 5. SINGLE WALLWITH INTERNAL BLADDER SYSTEM <br /> (Checkono NemoigQ ❑ 2. DOUBLEWALL EKTERIOR MEMBRANE LINER 095. UNKNOWN <br /> D 4. SINGLE WALL IN A VAULT ON. OTHER <br /> TANK MATERIAL-pdmary tank ❑ 1. BARE STEEL W/T FIBERGLASS/PLASTIC ❑ 5. CONCRETE 095. UNKNOWN <br /> (ChecNanedempnly) 0 2. STAINLESS STEEL U 4. STEEL CLAD WIFIBERGLASS 08. FRP COMPATIBLE W100%METHANOL 099. OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-eerondaglank ❑ 1 BARE STEEL MS.IFIBERGLASS/PLASTIC 0 B. FRP COMPATIBLE W/100%METHANOL 095. UNKNOWN <br /> (Check nhe 4em onW ❑ 2. STAINLESS STEEL D 4. STEEL CLAD W/FIBERGLASS 0 9. FRP NON-CORRODIBLE JACKET 094 OTHER <br /> REINFORCED PLASTIC(FRP) [110. COATED STEEL <br /> 0 5. CONCRETE <br /> TANK INTERIOR LINING ❑ 1. RUBBER LINED 0 3. EPDXY LINING 0 5. GLASS LINING 095. UNKNOWN433 DATEINSTALLED <br /> OR COATING <br /> ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING [3PL UNLINED 098.OTHER (Forloral use onl <br /> Checkonesemo ) <br /> OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC D 3, FIBERGLASS REINFORCED PLASTIC 095. UNKNOWN 434 DATEINSTALLED <br /> PROTECTION IF APPLICABLE PROTECTION <br /> ❑ 4. IMPRESSED CURRENT 0 99 OTHER (Forlawl use ony) <br /> (Check orre Nem ony) ❑ 2.SACRIFICIAL ANODE. <br /> SPILL AND OVERFILL - YEAR INSTALLED TYPE(Forbcal...n1y) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (Checketlfhatapply) QX SPILL CONTAINMENT 0 1.ALARM 3. FILL TUBE SHUT OFF VALVE <br /> Lvt. DROP TUBE 0 2. BALL FLOAT_ D 4.EXEMPT <br /> g­�'STRIKER PLATE <br /> 'IV.TANK LEAK DETECTION <br /> IF SINGLE WALL TANK(Check ell fhafapply): IF DOUBLE WALL TANK OR TANK WITH BLADDER(Check ane item ony)' <br /> ❑ 1, VISUAL(EXPOSED PORTION ONLY) D 5. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALLIN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) D S. VADOSEZONE ❑ 2. CONTINUOUS INTERSTITIAL MONITORING <br /> ❑ 3. CONTINUOUSATG. - 0 T. GROUNDWATER 0 3. MANUALMONITORING <br /> ❑ 4. STATISTICAL INVENTORY RECONCIUATION(SIR)« 0 B. TANKTESTING <br /> BIENNIAL TANK TESTING 099. OTHER <br /> V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YRfMOIDAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLEDWITH INERT MATERIAL? <br /> nagana - 0 Yea 0 No <br /> CUPAFORM(4/99) Formerly SWRCB Form B <br />