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Zy lL. D <br /> r B� <br /> UNIFIED PROGRAM CONSOLIDATED FORM TAN S <br /> UNDERGROUND STORAGE TANKS - TANK PAGE 1 \1� <br /> (two pages per cask) <br /> Pege hf <br /> TYPE OF ACTIONI NEW SITE PERMIT [34 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION [16 TEMPORARY SITE CLOSURE <br /> (Check one imm only) rk ❑ 7 PERMANENTLY CLOSED ON SITE <br /> ❑ 3 RENEWAL PERMIT (Spmifymamn-fmkaraluseeniy) (specifyreatem-fsolocaleeonly) ❑ 8 TANK REMOVED 430 <br /> BUSINESS NAW(same as FAC vNAMe or DBA-Doing Businm FACILITY ID: <br /> 3 <br /> LOCATION WITHIN SITE(optional) 431 <br /> 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.) <br /> TA,N1C ID# 06�� Z TA MANUFACTURER 433 COMPARTMENTALIZED TANK [I Yes C1 No 4M <br /> �-lf/Y es If"Yet',complete ane pse for each compw ent. <br /> DATE INSTjLLED(XE O) 435 TANK CAPACITY IN GALLONS 4 NUMBER OF COMPARTMENTS 437 <br /> ADDITIONAL DE CRIPTION(For local use only) 438 <br /> II.TANK CONTENTS <br /> TANK USE 039 PETROLEUMTYPE 440 <br /> L MOTOR VEHICLE FUEL ❑ In. REGULAR UNLEADED ❑ LEADED ❑5. JET FUEL <br /> f marked complete Petroleum Type) ❑lb. PREMIUM UNLEADED 3. DIESEL ❑6. AVIATION FUEL <br /> ❑2. NON-FUEL PETROLEUM ❑Ic. MIDGRADE UNLEADED 4. GASOHOL ❑99.OTHER <br /> [13. CHEMICAL PRODUCT COMMON NAME (ft.H...M me Materials fvmtory page) 441 GAS#(from Havrdow Materials Invemory page) 4/2 <br /> ❑4. HAZARDOUS WASTE <br /> (Include Uscd Oil) <br /> [195.UNKNOWN <br /> Ir. TANK CONSTRUCTION <br /> TYPE OF TANK 0 I. SINGLE WALL 3, SINGLE WALL WITH 0 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 <br /> (Check one imm only) EXTERIOR MEMBRANE LINER ❑95.UNKNOWN <br /> )(2. DOUBLE WALL ❑4. SIGNLE WALL IN VAULT [199. OTHER <br /> TANK MATERIAL-primer,tank I. BARESTEEL 3. FB3ERGLASS/PLASTIC 5. CONCRETE 95. UNKNOWN 444 <br /> (Check one item only) ❑2. STAINLESSSTEEL 4. STEEL CLAD W/FIBERGLASS 08. FRP COMPTIBLE W/100%METHANOL ❑99.OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-smondary tank Lj 1. BARE STEEL . FIBERGLASS/PLASTIC 5. CONCRETE 95. UNKNOWN 445 <br /> (Check one item only) ❑2. STAINLESS STEEL 4. STEEL CLAD WTIBERGLASS ❑8. FRP COMPTIBLE W/100%METHANOL [199.OTHER <br /> REINFORCED PLASTIC(FRP) ❑10.COATED STEEL <br /> ❑5. CONCRETE <br /> TANK INTERIOR LINING 1.RUBBER LINED ❑3.EPDXY LINING 5.GLASS LINING 0 95.UNKNOWN 446 DATE INSSTAiLLLLE/DD 447 <br /> OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING ❑6 UNLINED ❑99 OTHER <br /> (Check one item only) (For lhoal use only) <br /> OTHER CORROSION ❑1 MANUFACTURED CATHODIC ❑3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN DATE INSTALLED 449 <br /> PROTECTION IF APPLICABLE PROTECTION ❑4 IMPRESSED CURRENT ❑99 OTHER <br /> (check one item only) ❑2 SACRIFICIAL ANODE (For local use only) <br /> SPILL AND OVERFILLYEAR INSTALLED ��a// 450 TYPE(local um only) 451 OVERFILL PROTECTION EQUIPMENT:YFAR INSTALLED i 452 <br /> (Check all that apply) &SPILL CONTAINMENT 0(1 1 ALARM UA-. K3 FILL TUBE SHUT OFF VALVE <br /> X 2 DROP TUBE 06, L� BALL FLOAT ❑4 EXEMPT <br /> 3STRIKERPLATE 04- , Il <br /> IV.TANK LEAK DETECTION(A description ofthe monitoring pmgum shall be mbmiaed he the local a8emy.) <br /> IF SINGLE WALL TANK(Checkau that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 <br /> (Check one item only) <br /> ❑ I VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MTG) [I I VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑2 AUTOMATIC TANK GAUGING(ATG) ❑6 VADOSE ZONEI7L2 CONTINUOUS INTERSTITIAL MONITORING <br /> ❑3 CONTINUOUS ATG ❑7 GROUNDWATER 3 MANUAL MONITORING <br /> ❑4 STATISTICAL INVENTORY RECONCILIATION ❑STANK TESTING <br /> (SIR) BIENNIAL TANK TESTING 09 OTHER <br /> IV.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YR/MO/DAY) 055 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 <br /> gallons []Yes ❑ No <br /> UPCF(12/99 revised) 10 Formerly SWRCB Form B <br />