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' LIN IF I ED PROGRAM CONSOLIDATED FORM <br /> ANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 �cdl�J-I�q <br /> l l (fHy pages per tank) <br /> Pape _ of <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 4.AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION) ❑ 8. TEMPORARY SITE CLOSURE <br /> (Check one kens only) ❑ 1. PERMANENTLY CLOSED ON SITE <br /> ❑3.RENEWAL PERMIT (Speo/y resew-horkroal m wily) (Spooky chmge-kriocal use only) ❑ S. TANK REMOVED 430 <br /> BUSINESS NAME(Sema a FACILITY NAME or DBA-Doing Business As) FACILITY ID# 1 <br /> IAew q��o <br /> LOCATION`MTHIN SITE(Opfipnaq <br /> 1.TANK DESCRIPTION <br /> TANK ID TANK MANUFACTURER COMPARTMENTALIZED TANK 11 Y.. o <br /> oa E-9n t4 ^ L01 N b If-Yea,oomplele one page for eaNM compadment. <br /> DATEINSTALLED(YEARRAO) TANK CAPACITY IN GA1.1_0145 NUMBER OF COMPARTMENTS <br /> h-f lso3 ( d <br /> ADDITIONAL DESCRIPTION(ForWal vee only) <br /> fl.TANK CONTENTS <br /> TANK USE 432 PETROLEUM TYPE <br /> 1. MOTOR VEHICLE FUEL �a. REGULAR UNLEADED 112. LEADED ❑ S. JET FUEL <br /> (I dad,Eomplsfe Pahohnnn Type) 11lb PREMIUM UNLEADED ❑ 3. DIESEL ❑ B. AVIATION FUEL <br /> ❑ 2. NON-FUEL PETROLEUM 01c MIDGRADE UNLEADED ❑ 4, GASOHOL 099. OTHER <br /> ❑ 3. CHEMICAL PRODUCT <br /> ❑ 4. HAZARDOUS WASTE(Includes COMMON NAME(hwn Hazardous Materials Inronfprypaga) CAS#(from Hazandous Mafedals Inronfury Page) <br /> Used Od) <br /> 1195 UNKNOWN <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK 1. SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ S. SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> (Check one dem only) �2. DOUBLEWALL EXTERIOR MEMBRANE LINER 095. UNKNOWN <br /> [34, SINGLE WALL IN A VAULT ON, OTHER <br /> TANK MATERIAL.primary lank 1 BARE STEEL ❑ 3. FIBERGLASS/PLASTIC ❑ 5. CONCRETE 095. UNKNOWN <br /> (Check one dem only) ❑ Z STAINLESSSTEEL 4, STEEL CLAD W/FIBERGLASS ❑ 8. FRP COMPATIBLE W11 W%METHANOL 1199. OTHER <br /> REINFORCED PLASTIC FRP) <br /> TANK MATERIAL-secondary tank 0 1 BARESTEEL �❑./3. FIBERGLASS/PLASTIC ❑ 8. FRP COMPATIBLE WflW%METHANOL ❑95. UNKNOWN <br /> (Chackenelfemonly) ❑ 2. STAINLESS STEEL !0 d.STEEL CLAD WIFIBERGUSS ❑ 9. FRP NON-CORRODIBLE JACKET Cl 99. OTHER <br /> '` REINFORCED PLASTIC(FRP) Oto. COATED STEEL <br /> ❑ S.CONCRETE <br /> TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING ❑95. UNKNOWM433 DATEINSTALLED <br /> OR COATING <br /> ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING 96. UNLINED ❑99. OTHER Fprlocal used ) <br /> (THEN one limon ) i� <br /> POTHER ROTECTION <br /> IF ON ❑ 1 MANUFACTURED CATHODIC ra123, FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN 434 DATE INSTALLED <br /> PROTECTION IF APPLICABLE PROTECTION <br /> ❑ d. IMPRESSED CURRENT ❑89. OTHER <br /> (Check orro Nem only) ❑ 2. SACRIFICIALANODE (Forlocal use only) <br /> SPILLANDOVERFILL YEAR INSTALLED TYPE(Forwal use only) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (Check aM fhaf appy) 0 1 SPILL CONTAINMENT . 14y ❑ 1.ALARM I9'3. FILL TUBE SHUT OFF VALVE <br /> 13 2. <br /> �2. DROPTUBE � �QZ BALL FLOAT ❑ 4. EXEMPT <br /> ❑ 3. STRIKER PLATE <br /> :. IV. TANK LEAK DETECTION <br /> IF SINGLEWALL TANK Click al that apply): IF DOUBLE WALL TANK OR TANK WITH BLADDER(Check one item onl): <br /> ❑ 1, VISUAL(EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAVGING(MTG) 01. VISUAL(SINGLE WALLIN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATE) - 11 S. VADOSEZONE 00 2. CONTINUOUS INTERSTITIAL MONITORING , <br /> 113. CONTINUOUSATG 11T. GROUNDWATER 3. MANUAL MONITORING <br /> ❑ 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(YRIMOIDAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLEDWATH INERT,MATERIAL? <br /> gallons ❑yes ❑No <br /> CUPAFORM(4199) • Formerly SWRCB Form B <br />