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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 1 <br /> (hero pages par tank) <br /> Page _ of <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT 0 4. AMENDED PERMIT 0 5. CHANGE OF INFORMATION) 0 e. TEMPORARY SITE CLOSURE <br /> (Check on.M.onW D T. PERMANENTLY CLOSED ON SITE <br /> 03.RENEWAL PERMIT (Speaty Mason-forlocalu only) (Specify cMnpe-forrocN use onM 0 8. TANKREMOVEO 430 <br /> BUSINESS NAME(Be..as FACILITY NAME or DSA-Dcin9 Business As) FACILITY IO M 1 <br /> LOCATION WITHIN SITE(Opgonap 431 <br /> I.TANK DESCRIPTION <br /> TANK IDM TANK MANUFACTURER COMPARTMENTALIZED TANK 0 Yes 0 No <br /> (-7 a ©c�L- Yei omplNe ono page a eaC ompe h ant. <br /> DATE INSTALLED(YEARIMO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> ADDITIONAL DESCRIPTION(Parlocal use moy) <br /> ILTANKCONTENTS <br /> TANK USE 432 PETROLEUM TYPE <br /> ❑ 1. MOTOR VEHICLE FUEL 0Ia. REGULAR UNLEADED ❑ 2. LEADED D 5. JET FUEL <br /> (hmarked,compHro PefMbum Type) 1118. PREMIUM UNLEADED ❑ 3. DIESEL 0 5. AVIATION FUEL <br /> ❑ 2. NON-FUEL PETROLEUM D1c MIDGRADE UNLEADED ❑ 4.GASOHOL 099.OTHER <br /> ❑ 3. CHEMICAL PRODUCT <br /> 0 4. HAZARDOUS WASTE(hxdWes COMMON NAME(fnm Razahfous MahMmftihw tart'Page) CAS 0(Mm Nazaet Mahshals MAR,lowpagel <br /> Used Oig <br /> 173 95 UNKNOWN <br /> 111.TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1. SINGLE WALL 0 3. SINGLE WALL WTH D 5. SINGLE WALL WITH INTERNAL BUDDER SYSTEM <br /> (Check one it..osm ❑ 2. DOUBLE WALL EXTERIOR MEMBRANE LINER 095. UNKNOWN <br /> 0 4. SINGLE WALL IN A VAULT D 99. OTHER <br /> TANK MATERIAL-primary lank 0 1 BARE STEEL ❑ 3. FIBERGUSS/PLASTIC ❑ 5. CONCRETE 095. UNKNOWN <br /> (Check she from aW 0 2. STAINLESS STEEL 04. STEEL CUD WIFIBERGUSS 0 S. FRP COMPATIBLE WH00%METHANOL 1199. OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-secondary tank 0 1 BARE STEEL D 3. FIBERGLASS/PLASTIC 0 9. FRP COMPATIBLE W1100%METHANOL D95. UNKNOWN <br /> (ClMckomiNmany) 0 2, STAINLESS STEEL 0 4. STEEL CUD WIFISERGUSS D 9, FRP NON-CORROOIBLE JACKET D99. OTHER <br /> REINFORCED PLASTIC(ERR) 010. COATED STEEL <br /> 0 5. CONCRETE <br /> TANK INTERIOR LINING 0 1. RUBBER LINED D 3. EFOXY LINING ❑ 5. GLASS UNING 085. UNKNOW1,433 DATE INSTALLED <br /> OR COATING <br /> ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING ❑ B. UNLINED ❑89. OTHER (F'Iacal useanl) <br /> (Check ane esm on ) <br /> OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC D 3. FIBERGLASS REINFORCED RUSTIC ❑95. UNKNOWN 434 DAIS INSTALLED <br /> PROTECTION IF APPLICABLE PROTECTION <br /> ❑ 4. IMPRESSED CURRENT C1 99 OTHER <br /> (Check one item only) D 2. SACRIFICIAL ANODE (F tical use only) <br /> SPILL AND OVERFILL YEARINSTALLED TYPE(Far local use ohly) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (Lhocka4Metapp0') 0 1. SPILLOONTAINMENT ❑ 1.ALARM ❑ 3. FILL TUBE SHUT OFF VALVE <br /> 0 2. DROP TUBE 0 2. BALL FLOAT ❑ 4. EXEMPT <br /> D 3. STRIKER PLATE <br /> - N. TANK LEAK DETECTION <br /> IF SINGLE WALL TANK Check as that apply) IF DOUBLE WALL TANK OR TANK WITH BUDDER iChock om item nnl : <br /> ❑ 1. VISUAL(UPOSED PORTION ONLY) 0 5. MANUAL TANK GAUGING(MTG) 0 1. VISUAL(SINGLE WALLIN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) D B. VADOSE ZONE 0 2. CONTINUOUS INTERSTITIAL MONITORING <br /> 0 3. CONTINUOUSATG - 11 T. GROUNDWATER 0 3. MANUAL MONITORING <br /> 0 4. STATISTICAL INVENTORY RECONCILIATION(SIR) 0 S. TANKTESTING <br /> BIENNIAL TANK TESTING 099. OTHER <br /> V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE UST USED(YRNWAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 1 TANK FILLED WITH INERT MATERIALS <br /> gallon. 0 Yes D No <br /> CUPAFORM(4199) • • o"eily SWRCB Folm B <br />