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�I5f°7 i3 ✓ . ,..- .� /err UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE i (two pages per tank) Page_of_ TYPE OF ACTION 19k, NEW SITE PERMIT ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Chat one item only) ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT (Specify reason-for local we only) (Specifyreason-for local use only) ❑ 8 TANK REMOVED 470 BUS ESS NAME(Same as FACILITY NAME or DBA-Doing Business As) FACILITY ID: I erl l D Z_ 3 LOCATION WITHIN SITE(optional) _ _ 431 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# 012 TANK /MANUFACTUI!I 417 COMPARTMENTALIZED TANK Yes No 474 oZ 3 ✓j v sN o�.V If"Yes.complete one page for each compar mens. DATE INSTA--LL//�ED(YEAR/MO) 433 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 !X/O c 0 ADDITIONAL DESCRIPTION(For local use only) 43S _ II.TANK CONTENTS TANK USE 439 PETROLEUM TYPE - 447 t ❑1. MOTOR VEHICLE FUEL [Ila. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL i (if marked complete Petroleum Type) ❑Ib. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION FUEL NON-FUEL PETROLEUM ❑ Ic. MIDGRADE UNLEADED ❑4. GASOHOL OTHERO/Z `f 3. CHEMICAL PRODUCT CQMMON NAME(from Han d.Materiab Inrenmry page) 441 CAS#(firm Hazardous Material,In wrpap) 442 ❑4. HAZARDOUS WASTE J (Inchtdes Used Oil) (�!V ❑95.UNKNOWN III. TANK CONSTRUCTION TYPE OF TANK ld.L SINGLE WALL U 3. SINGLE WALL WITH 0 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one item only) EXTERIOR MEMBRANE LINER ❑95. UNKNOWN ❑2. DOUBLE WALL ❑4. SIGNLE WALL IN VAULT ❑99. OTHER TANK MATERIAL-primary ud . BARE STEEL Lj 3. FIBERGLASS/PLASTIC 5. CONCRETE Ll 95. UNKNOWN 444 (Check one item only) ❑2. STAINLESS STEEL [34. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPTIBLE W/100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-setwndaryma LJ I. BARE STEEL U 3. FIBERGLASS/PLASTIC 0 5. CONCRETE U 95. UNKNOWN 44 (Chat one item only) ❑2. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS P8. FRP COMPTIBLE W/100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10.COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING 1.RUBBER LINED 0 3.EPDXY LINING U 5.GLASS LINING El 95.UNKNOWN 446 DATE INSTALLED 447 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING � (Check one item only) v\UNLINED ❑99 OTHER (Far local use only) OTHER CORROSION ❑1 MANUFACTURED CATHODIC ❑3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN I DATE MSTALLED 449 PROTECTION IF APPLICABLE PROTECTION . ❑4 IMPRESSED CURRENT ❑99 OTHER (Check one iters only) ❑2 SACRIFICIAL ANODE (For local use only) SPILL AND OVERFILL YEAR INSTALLED 450 TYPE(local use oely) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Chat all that apply) ❑1 SPILL CONTAINMENT ❑1 ALARM 3 FILL TUBE SHUT OFF VALVE ❑2 DROP TUBE /� [32 BALL FLOA�� ❑4 EXEMPT ❑3 STRIKER PLATE IV.TANK LEAK DETECTION(A description of the monitoring program shall be submitted to the local agency.) IF SINGLE WALL TANK(Check all that apply) 437 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 (Checkone item only) ❑1 VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MTG) ❑1 VISUAL(SINGLE WALL IN VAULT ONLY) ❑2 AUTOMATIC TANK GAUGING(ATG) ❑6 VADOSE ZONE ❑2 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) 433 1 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT TERIAL? 457 gallons ❑Yes No UPCF(12/99 revised) 10 Formerly SWRCB Form B