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U NIFIED PROGRAM CONSOLIDATED FORM TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 <br /> (Mro pages per tank) <br /> Page <br /> �.CHANGE OF INFORMATION? ❑ 5. TEMPORARY SITE CLOSURE <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT D a. AMENDED PERMIT ❑ T. PERMANENTLY CLOSED ON SITE <br /> (Check one item only) <br /> ❑3.RENEWAL PERMIT (Spxlynuon-rorlool use oMy) IS,*charge-b,ppal useonly) 08. TANK REMOVED 430 <br /> t <br /> B SINESS NAME(Same as FACILITY NAMEor DBA-Doing Bu' esa Aa) FACILITY ID tl <br /> O ' <br /> Q ��nc_ (T�[1c t GZf S <br /> LOCATION WITHIN SITE(OPdm' ryry 431 <br /> v <br /> 1 I.TANK DESCRIPTION <br /> TANK I0tl TANK MANUFACTURER COMPARTMENTALIZED TANK 0 Yea <br /> I(9ei,.,let.ate one page bT eaN mmparSnanL <br /> -f- (D-�{D % n �p TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> DATE INSTALLED(YEARRAO) 1 <br /> ADDITIO LO RIPTION(FOTlxal uaa any) <br /> It.TANK CONTENTS <br /> TANK USE 432 cn PETROLEUM TYPE 0 5. JET FUEL <br /> - <br /> 5d1. MOTOR VEHICLE FUEL SZILa REGULAR UNLEADED ❑ 2. LEADED <br /> V madeJ,complete Patmleum Type) 0 3 DIESEL D 8. AVIATION FUEL <br /> '( ❑1D PREMIUM UNLEADED Ogg, OTHER <br /> 0 2. NON-FUEL PETROLEUM 01c. MIDGRADEUNLEADED 0 4. GASOHOL <br /> 0 3.CHEMICALPRODUCT COMMON CA$tl(hom NaxeNom Mafedela lnvenrorypage) <br /> NAME(fmm Haxardaus Mafehals Invenforypaye) <br /> 0 4. HAZARDOUS WASTE(Inclutles <br /> Uand Olp <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK 01, SINGLE WALL 0 3. SINGLE WALL WITH D 5. SINGLE WALL WITH INTERNAL BUDDER SYSTEM <br /> -IEXTERIOR MEMBRANE LINER 095. UNKNOWN <br /> (Chspk one item any) T9 . DOUBLEWALL eD 4. SINGLE WALL IN A VAULT 099. OTHER <br /> TANK M t-mL-pnmary Unk 1 ARE STEEL <br /> ❑ 3. FIBERGLASS I PLASTIC 0 5. CONCRETE 095. UNKNOWN <br /> (Check ensn.item pny) ❑ Z. STAINLESS STEEL ❑<. STEEL CLAD WIFIBERGLA55 ❑ B FRP COMPATIBLE WH0095 METHANOL 0. OTHER <br /> REINFORCED PLASTIC IFRPI <br /> iom <br /> T <br /> TANK MATERIAL-semnCary tan BARE STEEL 0 3. FIBERGLASS/PUSTIC 08 FRP COMPATIBLE W110%METHANOL 095. H <br /> (Check One item any) t. STAINLESS STEEL ❑ 4 REINFORCED PLASTIC(RPS 010. COATED S RROCABLE JACKET EL <br /> ❑99. OOTHEERR <br /> 0 5. CONCRETE pATE INSTALLED <br /> TANK INTERIOR LINING 01, RUBBER LINED 0 3tl <br /> . EPDXY LINING D 5. GLASS LINING 095. UNKNOWN ] <br /> OR COATING PHENOLIC LINING 0 5. UNLINED 099. OTHER (Fprlocaluse only) <br /> 02 ALKYD LINING DATEINSTALLED <br /> CO <br /> (Check Bemand 1 <br /> OTHER CORROSION b(I MANUFACTURED CATHODIC J. FIBERGLASS REINFORCED PLAUNKNOWN 434 <br /> STIC 95. U <br /> PROTECTION R APPLICABLE PROTECTION ❑ 4. IMPRESSED CURRENT 099.OTHER (Forlocal use only) <br /> (Chackmei(emonly) ❑ 2. SAORIFICIALANODE OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED - <br /> SPILL AND OVERFILL <br /> YFAft INSTALLED TYPE(FmlacM me any) <br /> (Check a0 that appy) 1. SPILL CONTAINMENT 1. ALARM _ 0 3, FILL TUBE SHUT OFF VALVE <br /> 0 2. DROP TUBE 0 2, BALL FLOAT__ ❑ 4. EXEMPT <br /> ❑ 3. STRIKER PLATE <br /> IV.TANK LEAK DETECTION - <br /> IF DOUBLE WALL TANK OR TANK WITH BUDDER(Check one item aMy)' <br /> IF SINGLE WALL TANK CNck ell that R <br /> ❑ 5. MANUAL TANK GAUGING INTO) 0 1. VISUAL(SINGLE WALL?NALVAULT <br /> MONITORING❑ 1. VISUAL(EXPOSEp P00.TION ONLY) �2 CONTINUOUS INTERSTITIAL MONITORING ' <br /> D 2. AUTOMATIC TANK GAUGING(ATG) 0 8. VADOSEZONE <br /> ❑ T. GROUNDWATER ❑ 3. MANUAL MONITORING <br /> ❑ 3. CONTINUOUS ATO <br /> 0 4. STATISTICALINVENTORY RECONCILIATION(SIR) ❑ B. TANKTESTING <br /> BIENNIAL TANK TESTING ❑99. OTHER�� <br /> V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE <br /> ESTIMATED QUANTITY OF SUBSTANCE REMAINING <br /> 435 TANK FILLED WITH INERT MATERIAL? <br /> ESTIMATED DATE LAST USED(YRIMOIDAY) <br /> galloae ❑Yes ❑No <br /> i0py <br /> (J l/ <br /> /D I Formerly SWRCB Form <br /> C/J_ a 1[ 8 <br /> CUPAFORM(4199) 0 <br />