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UNIFIED PROGRAM CONSOLIDATED FOR <br /> [E::= <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 TANKS <br /> �� fl" rAo( <br /> TYPEOFACTION ❑1.NEWSITE PERMIT ❑ 4.AMENDED PERMIT Pepe _ <br /> (Check aro Mm onM 0 5. CHANGE OF INFORMATION) - ❑ a, TEMPORARYSITE CLOSURE n <br /> 03.RENEWAL PERMIT (5�.�-xon� b LKT. PERMANENTLY CLOSED ON BIT /ly'��D� <br /> (SFxNY chugs-brbal use only) <br /> BUSINESS NAME(Bame as FACILITY NgME wDBA-Dolnp eusness As) 0 S. TANK REMOVED 930 <br /> W0/d16-N 'S C .� dlC FAclu Y10# <br /> EJlJ7C. .SIP/f�v�.�QCI/rt1 C 1 <br /> LOCATION NA <br /> IH.SITE(Opf .0 431 <br /> 5ADDITTIO�L <br /> I.TANK DESCRIPTION <br /> TANK MANUFACTUREq <br /> UNK.WuJN COMPARTMENTAUZEO TANK ❑ Yes �1 No <br /> LED(YEA 0) A N'Yes"mmplero one Pape br aaU mmpartmeM. <br /> TgNK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> D Rl"ON 50-DESCRIPTION(Fprlocal usa only) <br /> TANK USEII.TANK CONTENTS <br /> 432 PETROLEUM TYPE <br /> 0 1. MOTOR VEHICLE FUEL ❑1a. REGULAR UNLEADED ❑ <br /> (#mamep,-PMe Pefmleom Type) 2, LEADEDtb. PREMIUM UNLEADED 5. JET FUEL <br /> ❑ 2. NON-FUEL PETROLEUM 3. DIESEL ❑ B. AVIATIONFUEL <br /> ❑ 3. CHEMICAL PRODUCT MIDGRADE UNLEADED ❑ 4. GASOHOL <br /> 09. OTHER <br /> ❑ 4. HAZARDOUS WASTE(Indaaa COMMON NAME(/mm N#Zda10Y4 Mafe#aAs/nwn(oryp,a) <br /> UseCAB Dip CAS#(ft.Mazemoux Mabnalx InwnbryPa9eJ <br /> WN <br /> TYPE OF TANK <br /> 111.TANK CONSTRUCTION <br /> �A 1. SINGLE WALL <br /> 0 ❑ 3.SINGLIE TERIOR LL WITHMEMBRANE <br /> ❑ S. SINGLE WALL HATH INTERNAL BLADDER SYSTEM <br /> ' (Check one it..oNy) ❑ 2. DOUBLE WALL EXTERIOR MEMBRANE LINER <br /> 04.SINGLE WALL IN A VAULT 085. UNKNOWN <br /> 1199. OTHER <br /> TANK MATERIAL pnnary WAA1 DARE STEEL 0 3. FIBERGLASS/PUBTIC 0 5. CONCRETE <br /> (Ch.komifemoW ❑ 2.STAINLESSSTEEL 04. STEELCLADWIFIBERGLA$$ ❑ B. FRP COMPATIBLE W1100%METHANOL ❑Bp. OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-aeranaary Mnk 1 BARE STEEL 0 3. FIBERGUSS/PUSTIC 0 S. FRP COMPATIBLE WIlD METHANOL �95, UNKNOWN <br /> (Check omftem only) ❑ 2. STAINLESS STEEL 04. STEEL CLAD W/FIBERGUSS ❑ 9. FRP NON-CORRODIBLE JACKET 13 99. OTHER <br /> REINFORCED PLASTIC(FAP) <br /> 1110. COATED STEEL <br /> ❑ 5.CONCRETE <br /> TANK INTERIOR LIMING 1, RUBBER LINED 0 3.EPDXY LINING DATE INSTALLED <br /> OR COATING 0 5. GLASS LINING A9 95. UNKNOWN433 <br /> (Check ono"mEl2.ALKYD LINING 04. PHENOLIC LINING 0 S. UNLINED ❑99. OTHER <br /> OTHER I� (Far lomloxe only) <br /> PROTECTION <br /> IF ATN ❑ 1. MANUFACTIMED CATHODIC 0 3. FIBERGLASS REINFORCED PLASTIC �95, UNKNOWN 434 DATEINSTALLED <br /> PROTECTION IF APPLICABLE PROTECTION <br /> ❑4. IMPRESSED CURRENT 099. OTHER <br /> (Check Pne dem aW 0 2.SACMFICW-ANODE <br /> (Fprlocal use ony) <br /> SPILLANDOVERFlLL g ALLED TYPE(Forbcalexe owy) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (Check ell Thal 9AW 0 1. SALL MCONTAINIF11f��A <br /> ❑ 1.ALARM ❑ 3. FILL TUBE BRUT OFF VALVE_ <br /> 0 2. DROP TUBE ❑ 2. BALL FLOAT_ 0 4. EXEMPT <br /> 0 3. STRiKEP P-ATEE <br /> Al.TANK LEAK DETECTION <br /> 6 SwG1.E wALL TANK Checke3erf IF DOUBLE WALL TANK OR TANK WITH BLADDER CMck one item on ): <br /> 01, VISUAL(EXPOSED PORTION ONLY) 05. MANUAL TANK GAUGING(MTG) 01. VISUAL(SINGLE WALLIN VAULT ONLY) <br /> 0 2. AUTOMATIC TANK GAUGING(ATG) 0 S. VADOSEZONE 0 2. CONTINUOUS INTERSTITIAL MONITORING <br /> 0 3. CONTINUOUSATG 0 T. GROUNDWATER 0 3, MANUALMONITORING <br /> 0 L STATISTICALINVENTORY RECONCILIATION(SIR). 0 S. TANKTESTING <br /> BIENNIAL TANK TESTING - [IN. OTHER <br /> V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YRMIOIDAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL? <br /> pallors <br /> ❑Yes ❑Na <br /> CUPAFORM(4/99) <br /> Formerly SWRCB Form F <br />