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U N IF I EDP ROG RAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 1 <br /> (Mo pages per tank) <br /> P _ of _ <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 4.AMENDED PERMIT ❑ 5. CHANGE OF INFORMATION) ❑ 8. TEMPORARY SITE CL RE <br /> (Check one tram o*) ❑ T. PERMANENTLY CLOSEC ONSITE <br /> 113.RENEWAL PERMIT (Specify reason-forlmalun mly) fSOedTY clremp-brbnl vse aMy) ❑ B. TANK REMOVED 430 <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) FACILITY ION 1 <br /> Ei <br /> LOCATION WITHIN SITE(Gplim.q. 431 <br /> I.TANK DESCRIPTION <br /> TANK 10 0 TANK MANUFACTURER <br /> ^ 3 COMPARTMENTALIZED TANK ❑ i ❑ No <br /> I•••���...aaa <br /> � J ?.� D IPVai,complete one page lm eaCn compartment. <br /> DATE INSTALLED(YEARIk10) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> ADDITIONAL DESCRIPTION(Forbcal we mW <br /> II.TANK CONTENTS <br /> TANK USE 432 PETROLEUM TYPE <br /> ❑ 1. MOTOR VEHICLE FUEL ❑1a. REGULAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL <br /> (If marked,oomylafa Patmleum Type) ❑lb. PREMIUM UNLEADED ❑ 3. DIESEL ❑ S. AVIATIONFUEL <br /> ❑ 2. NON-FUELPETROLEUM ❑1c. MIDGRADEUNLEADED ❑ 4. GASOHOL ❑N. OTHER <br /> ❑ 3.CHEMICALPRODUCT <br /> ❑ 4. HAZARDOUS WASTE(Includes, COMMON NAME(/mm Hazaromre Maladablownforypage) CASJ,(bom Hazardous Matiml. nrorypepe) <br /> Used Oil) <br /> 13 95 UNKNOWN <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1. SINGLEWALL ❑ 3. SINGLEWALLIMTH ❑ 5. SINGLEWALLWITH INTERNALBUDOER SYSTEM <br /> (Check me item only) ❑ 2. DOUBLE WALL EXTERIOR MEMBRANE LINER 11 95. UNKNOWN <br /> ❑ 4. SINGLE WALL IN A VAULT ❑99. OTHER <br /> TANK MATERIAL-Ptlmary tank ❑ 1 BARE STEEL ❑ 3. FIBERGLASS I PLASTIC ❑ 5. CONCRETE Ll 95. UNK4 NMel <br /> (Check.rrekenri ❑ 2. STAINLESS STEEL ❑4. STEEL CLAD WIFIBERGLASS ❑ B. FRP COMPATIBLE Vol 00%METHANOL 11. OTHE <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-secondary lank ❑ 1 BARE STEEL ❑ 3. FIBERGLASSIPLASTIC ❑ 8. FRP COMPATIBLE W1100%METHANOL ❑85. UNK4 WN <br /> (Check..it..mW ❑ 2. STAINLESS STEEL ❑ 4. STEEL GAD W/FIBERGLASS ❑ 9. FRP NON-CORRODIBLE JACKET ❑99. OTRE <br /> REINFORCED PLASTIC(FRP) ❑%COATED STEEL <br /> ❑ 5. CONCRETE <br /> TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING 1195. UNKNOWN433 DA E INSTALLED <br /> OR COATING <br /> ❑ 2. ALKYD LINING 114. PHENOLIC LINING ❑ e. UNLINED ❑99. OTHER <br /> orf <br /> (Check s RemcmKil IF. Imal...nl <br /> OTHERCORROSION ❑ 1. MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PUSTIC ❑95. UNKNOWN 434 DA EINSTALLEO <br /> PROTECTION IF APPLICABLE PROTECTION <br /> ❑ 4. IMPRESSED CURRENT ❑N.OTHER <br /> (Chock ons from mty) ❑ 2. SACRIFICIAL ANODE (R+ Ixal use only) <br /> SPILL AND OVERFILL YEAR INSTALLED TYPE(Forlmal use only) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (Check all that apply) ❑ 1 SPILL CONTAINMENT ❑ 1. ALARM ❑ 3. FILL TUBE SHUT OFF VALVE <br /> ❑ 2. DROP TUBE ❑ 2. BALL FLOAT ❑ 4. EXEMPT <br /> ❑ 3. STRIKER PLATE <br /> IV.TANK LEAK DETECTION. <br /> IF SINGLE WALL TANK Chack ak that. IF DOUBLE WALL TANK OR TANK WITH BLADDER Check ne item <br /> ❑ 1, VISUAL(EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALLIN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATE) ❑ 8. VADOSEZONE ❑ 2. CONTINUOUS INTERSTITIAL MONITORING <br /> ❑ 3. CONTINUOUSATG ❑ T. GROUNDWATER ❑ 3. MANUALMONITORING <br /> ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR). ❑ B. TANKTESTING <br /> BIENNIAL TANK TESTING 11 99, OTHER <br /> V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE <br /> ESTIMATED GATE UST USED(YR/MOIOAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL? <br /> ESTIMATED DATE LAST USED(Y"O/DAY) 7 <br /> gallons 11 Yes Cl No <br /> CUPAFORM(4199) Formerly SWRCB Farm 8 <br />