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Zo Ir 0 2Nv -t�vtrtL- UNIFIED PROGRAM CONSOLIDATED FORMr;� NF1 TAN UNDERGROUND STORAGE TANKS -TANK PAGE I V B�� V)I% r' (two p s per tank) Page of TYPE OF ACTION 1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Check one item only) Jx ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT (Specify mason-forlocal au only) (Specify mance-falocd use only) ❑ 8 TANK REMOVED 430 BUSINESS (Same as FAC YNAME or DBA-Doing Businnu FACILITY 3 / LOCATION WITHIN SITE(opiimuU 431 I.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#�/7IO13 TA K MANUFACTURER 433 COMPARTMENTALIZED TANK ❑Yes ❑ No 434 +�j J ,S 1P'Yer%complete one page for each compenmeat. DATE INSTILLED EA O) 435 TANK CAPACITY IN GALLONS 6m NUMBER OF COMPARTMENTS 437 6 ADDITIOIVP.L DE CRIPTION(Far ictal one only) 438 IL TANK CONTENTS TANK USE 439 PETROLEUM TYPE 44a MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (1T'marked complete Permleum Type) ❑Ib. PREMIUM UNLEADED X3. DIESEL [16. AVIATION FUEL ❑2. NON-FUEL PETROLEUM ❑In. MIDGRADE UNLEADED ❑4. GASOHOL [199.OTHER [13. CHEMICAL PRODUCT COMMON NAME (ante Haa,rmu<Matedais lawntery pagc) 441 CAS#(from Hassrdous Materials Inventory page) 441 [14. HAZARDOUS WASTE (1.dudes used Oil) [195.UNKNOWN III. TANK CONSTRUCTION TYPE OF TANK 1. SINGLE WALL 03. SINGLE WALL WITH 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one imm only) EXTERIOR MEMBRANE LINER ❑95. UNKNOWN X2. DOUBLE WALL ❑4. SIGNLE WALL IN VAULT [199. OTHER TANK MATERIAL-pnmmy tank 1. BARE STEEL 3. FIBERGLASS/PLASTIC 5. CONCRETE 95. UNKNOWN 444 (Check ane man only) ❑2. STAINLESS STEEL 4. STEEL CLAD W/FBERGLASS ❑S. FRP COMPTIBLE W/100°/6 METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary lank U L BARE STEEL . FIBERGLASS/PLASTIC 5. CONCRETE 95. UNKNOWN 445 (Check one item only) ❑2. STAINLESS STEEL 4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPTBLE W/100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10.COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING ❑1.RUBBER LINED 3.EPDXY LINING 5.GLASS LINING 95.UNKNOWN 446 DATE MQSJ7�Aj.LLEEDD 447 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING ❑6 UNLINED ❑99 OTHER G - - ' 4 , ' (Check one immenly) (Furkceluseemly) OTHER CORROSION ❑ 1 MANUFACTURED CATHODIC ❑3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN 44S DATE INSTALLED 449 PROTECTION IF APPLICABLE PROTECTION ❑4IMPRESSED CURRENT ❑99 OTHER (Check one item only) ❑2 SACRIFICIAL ANODE (Far lonl us only) SPILL AND OVERFILL YEARINSTALLEDaa..ss// 450 TYPE(local uae only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED , 452 (Check all chat apply) Ki SPILL CONTAINMENT 0 16.1 ALARM 6/0, K3 FILL TUBE SHUT OFF VALVE 2 DROP TUBE 06, I') 2 BALL FLOAT ❑4 EXEMPT 3 STRIKER PLATE 194- , �l IV.TANK LEAK DETECTION(A do aiption of me monitodng pmgmm shall be submined m the local agency.) IF SINGLE WALL TANK(check an that apply) 4s3 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 (Check ane item only) ❑ I VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MTG) [I I VISUAL(SINGLE WALL IN VAULT ONLY) ❑2 AUTOMATIC TANK GAUGING(ATG) ❑6 VADOSE ZONE17L2 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 OTUMO/DAY) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 gallons ❑Yes ❑ No UPCF(12/99 revised) 10 Formerly SWRCB Form B