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UNIFIED PROGRAM CONSOLIDATED FORM <br /> =TANKSUNDERGROUND STORAGE TANKS -TANK PAGE $ <br /> Page _ of <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT C 4. AMENDED PERMIT ❑ 5. CHANGE OF INFORMATION) C e..TEMPORARY SITE CLOSURE <br /> (Check one item only) - C ?. PERMANENTLY CLOSED ON SITE <br /> 113.RENEWAL PERMIT (SI d,reason-furlooel use only) (Spft*chenga-forlocal use only) C S. TANK REMOVED 430 <br /> BUSINESS NAME(Same as FAULTY NAME or DBA-Doing Business As) FACILITY IDS 1 <br /> oe /r`-sto q 42 V 0 <br /> LOCATIONEM// THIN SIi�O� I 431 <br /> I.TANK pVsckiFnON <br /> TANK 10 �/ TANK MANUFACTURER COMPARTMENTALIZED TANK C Yes No <br /> A 0 a/J� ��tl%�y if'Yei,complete one page for eaU cam ent. <br /> fix <br /> DATEINSTALLED(Y RIMO) TANK CAPACITY IN GALLONS 4a NUMBER OF COMPARTMENTS ,a <br /> 9y U <br /> ADDITIONAL DESCRIPTION(For bol use arty) <br /> II.TANK CONTENTS <br /> \��]� TANK USE 432 PETROLEUM TYPE <br /> hl.'I�tc/TOR VEHICLE FUEL �❑tla. REGULIR UNLEADED ❑ 2. LEADED ❑ S. JET FUEL <br /> Mme-M1egcompleb PafnNeum Type) 19:5 PREMIUM UNLEADED ❑ 3. DIESEL C 8. AVIATIONFUEL <br /> ❑ 2. NON-FUELPETROLEUM ❑1c MIDGRADE UNLEADED ❑ 4. GASOHOL 0W. OTHER <br /> ❑ 3. CHEMIHAZARDAL OUS <br /> WA DDT COMMON NAME(Bom Hazntlous Materials lmanlorypape) <br /> ❑ 4. HAZARDOUS WASTE(ImluCes CAS#(ham Nezallous Meferrab Invenbrypeps) <br /> Used Oa) <br /> 95 UNKNOM <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK ❑ t SINGLE WALL C 3, SINGLE WALL NTH C 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> ((check one it..only) DOVBLE WALL EXTERIOR MEMBRANE LINER 1195, UNKNOWN <br /> C 4,SINGLE WALL IN A VAULT C W. OTHER <br /> TANK MATERIAL-porrary tank C 1 BARE STEEL 13 3. FIBERGLASBIPIASTIC ❑ 5. CONCRETE 095. UNKNOWN <br /> (CheckoneilemoMy) C 2, STAINLESS STEEL 'gN, STEEL CLAD WIFIBERGLASS ❑ 8. FRP COMPATIBLE W1100%METHANOL ❑99. OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-secondary tank O 1. BARE STEEL C 3. FIBERGLASS/PLASTIC ❑ 8. FRP COMPATIBLE W/1013%METHANOL ❑95. UNKNOPM <br /> (Check one item only) C 2, STAINLESS STEEL Q7 STEEL CLAD WIFIBERGLASS C 9. FRP NON-CORRODIBLE JACKET 099. OTHER <br /> REINFORCED PLASTIC(FRP) C 10. COATED STEEL <br /> C S.CONCRETE <br /> TANK INTERIOR LINING C 1. RUBBER LINED C 3. EPDXY LINING 05 GLASS LINING C95. UNKNCWN433 DATEINSTALLED <br /> OR COATING �/) <br /> ❑ 2.ALKYD LINING ❑ 4. PHENOLIC LINING �v-c UNIJNED 089. OTHER <br /> (CireOTHER CORROOn <br /> Forlocal use aril) <br /> OTHER CORROSIONC 1 MANUFACTURED CATHODIC C 3, FIBERGLASS REINFORCED PLASTIC C 95. UNKNOWN 434 GATE INSTALLED <br /> PROTECTION IF APPLICABLE PROTECTION <br /> ❑ I. IMPRESSED CURRENT 099. OTHER <br /> (Check one hem only) 112. SACRIFICIAL ANODE (Forboal use any) <br /> SPILL AND OVERFILL 1 YEAR INSTALLED TYPE(For local use only) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (Chelralthatappw C 1. SPILL CONTAINMENT C 1. ALARM &M FILL TUBE SHUT OFF VALVE <br /> C 2. DROPTUBE �12. BALL FLOAT C 4. EXEMPT <br /> C 3. STRIKER PLATE y A y <br /> IV. TANK LEAK DETECTION <br /> IF SINGLE WALL TANK Check ell that a IF DOUBLE WALL TANK OR TANK WITH BLADDER pChwk one item Only): <br /> C 1. VISUAL(EXPOSED PORTION ONLY) C 5. MANUAL TANK GAUGING(MTG) C 1. VISUAL(SINGLE WALL IN VAULT ONLY) <br /> C 2. AUTOMATIC TANK GAUGING(ATG) C 8. VADOSEZONE RM CONTINUOUS INTERSTITIAL MONITORING, <br /> C 3. CONTINUOUSAT13 C T. GROUNDWATER ❑ 3. MANUAL MONITORING <br /> C 4. STATISTICAL INVENTORY RECONCIUATION(SIR). C 8. TANKTESTING <br /> BIENNIAL TANK TESTING C99. OTHER <br /> V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YRIMO/DAY) ESTIMATED QUANTITY OF SUBSTANCE RESWNING 435 TANK FILLED HATH INERT MATERIAL? <br /> gallons - ❑Yes C No <br /> CUPAFORM(4/99) . Fonnerly SWRCB Form 8 <br />