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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 7 <br /> (two pages par tank) <br /> Pep _ of _ <br /> TYPE OF ACTION 01.NEW SITE PERMIT 0 4. AMENDED PERMIT 0 5, CHANGE OF INFORMATION) ❑ B. TEMPORARY SITE CLOS RE <br /> (Cheokone Mamony9 ❑ ]. PERMANENTLY CLOSED ON SITE <br /> D 3.RENEWAL PERMIT (SpeNlyreaaon-brkaeluseorxy) (Spectiy Change-lorbcM uxs oMyt ❑ S. TANK REMOVED 430 <br /> BUSINES$NAME($anon FACILITY NAM uDBA-DgylpBmin�» ,� FACILITYIOk 1 <br /> LOCATION WITHIN SITE(Opdonep 431 <br /> I.TANK DESCRIPTION <br /> TANKIDM TANK MANUFACTURER COMPARTMENTALIZED TANK ❑ Yes 0 No <br /> / �1 �_ O t If'Yea,complete one papa for eaN compMmenl. <br /> OATEINSTALLED(YEAR/MO) TANKWPACITYINWLLON5 NUMBER OF COMPARTMENTS <br /> ADDITIONAL DESCRIPTION(Forlocal axe wW <br /> IL TANK CONTENTS <br /> TANK USE t32 PETROLEUM TYPE <br /> 0 1. MOTOR VEHICLE FUEL Ola. REGULAR UNLEADED ❑ ]. LEADED 0 5.JET FUEL <br /> (M marked,complete Petroleum Type) D to PREMIUM UNLEADED ❑ 3. DIESEL 0 B. AVIATION FUEL <br /> 0 2. NON-FUEL PETROLEUM 0 to. MIOGNADEUNLEADED ❑ d.WSOHOL 099. OTHER <br /> 0 3.CHEMICAL PRODUCT COMMON NAME(hom Hazardom Malada/a Inkenrorypaye) <br /> 0 4. HAZARDOUS WASTE(Irkakdex CAStl(ft.HezeNoux Materials In ntoryppe) <br /> Uaad Dio <br /> 171 9s UNKNOWN <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1. SINGLE WALL 0.3. SINGLE WALL WITH ❑ S. SINGLE WALL HATH INTERNAL BLADDER SYSTEM <br /> (Check one Mem ony) ❑ 2, DOUBLEWALL EXTERIOR MEMBRANE LINER ❑95. UNKNOWN <br /> 0 4.SINGLE WALL IN A VAULT 99OTHER <br /> TANK MATERIAL-primary tank D 1 BARE STEEL 0 3. FIBERGLASS I PIASMC D 5. CONCRETE 1:195. UNO OWN <br /> (Check one item only) 0 2, STAINLESS STEEL D4. STEEL CUD W/FIBERGLASS 0 B. FRPCOMPATISLE W/100%METHANOL 099. OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-seetrdary lank ❑ 1 BARE STEEL 0 3. FI9ERGLASS/PLASTIC ❑ B. FRP COMPATIBLE W/100%METHANOL ❑95. UNKNOWN <br /> (Check we item only) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CUD WIFIBERGIASS 0 9. FRP NON-CORRODIBLE JACKET ❑99. OTHER <br /> REINFORCED PLASTIC(FRP) D10, COATED STEEL <br /> 0 5. CONCRETE <br /> TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING 0 5. GLASS LINING 095. UNKNOWN433 DA TEINSTALLED <br /> OR COATING <br /> ❑ 2. ALKYD LINING ❑ d. PHENOLIC LINING ❑ 8. UNLINED ❑0. OTHER <br /> ChecN one Mem only) F local use o <br /> OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC 095. UNKNOWN 434 D EINSTALLED <br /> PROTECTION IF APPLICABLE PROTECTION <br /> ❑ 4. IMPRESSED CURRENT 1199. OTHER <br /> (Ghackoru Mem.W ❑ 2. WCRIFICIALANODE (F rlxal use oMy) <br /> SPILL AND OVERFILL YEAR INSTALLED TYPE(Forlacaluseonly) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> ((Clackall that appy) ❑ 1 SPILL CONTAINMENT 0 1.ALARM 0 3. FILL TUBE SHUT OFF VALVE <br /> 0 2. DROPTUBE 0 2. BALL FLOAT 0 4. EXEMPT <br /> ❑ 3. STRIKER PLATE <br /> IV. TANK LEAK DETECTION. <br /> IF SINGLE WALL TANK(Check all than. ): IF DOUBLE WALL TANK OR TANK WITH BLADDER bech one dem any): <br /> 0 1, VISUAL(EXPOSED PORTION ONLY) ❑ S. MANUALTANKWUGING(MTG) ❑ 1. VISUAL(SINGLE WALLIN VAULT ONLY) <br /> D 2. AUTOMATIC TANK GAUGING(ATG) 0 B. VADOSEZONE ❑ 2. CONTINUOUS INTERSTITIAL MONITORING <br /> 0 3. CONTINUOUSATG. - 0 T. GROUNDWATER ❑ 3. MANUAL MONITORING <br /> Cl 4. STATISTICAL INVENTORY RECONCILIATION(SIR) ❑ 8. TANKTESTING <br /> BIENNIAL TANK TESTING 099. OTHER <br /> V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YRIMO/DAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL? <br /> peIt.. ❑Yes ❑No <br /> CUPAFORM(4/99) • • ormeriy SWRCB Form B <br />