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Aow UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 1 (tw»pages per tank) Page _ of _ TYPE OF ACTION ❑1.NEWSITE PERMIT ❑ 4.AMENDED PERMIT ❑ 5. CHANGE OF INFORMATION) ❑ S. TEMPORARY SITE CLOSURE (Check one ibm only) ❑ T. PERMANENTLY CLOSED ON SITE ❑3.RENEWAL PERMIT (Spedlyrseson-Ierlocal use 0*) (Spedlydlerga-brloul use Doty) .TANK REMOVED 430 BUSINESS NAME(Same as FACILITY NAME or OBA-fbing Business As) FACILITY IDN 1 ES?ATS f f /-�1 R u-��orw ra�83 T�4 s ss LOCATION WITHIN SITE(Opelli.0 1 Sfo G 4y-)z 1.TANK DESCRIPTION TANK IOC 01 TANKMANUFACTURER COMPARTMENTALIZED TANK ❑ Vchea Z.r it'Yas,complete one page ler eam arenenl. DATEINSTALLE�D(YFA�RJ/MyQ, TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS U/ri-M1C_. /o D ADDITIONAL DESCRIPTION(Fprbcel uae ody) II.TANK CONTENTS TANK USE 432 PETROLEUM TYPE X1. MOTOR VEHICLE FUEL ❑Is. REGULAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL (I/marked,complete Petroleum T),pe) 1:1 To. PREMIUM UNLEADED >r� DIESEL ❑ 8. AVIATION FUEL ❑ 2. NOWFUEL PETROLEUM ❑1c MIDGRADE UNLEADED ❑ 4. GASOHOL ❑99. OTHER ❑ 3.CHEMICAL PRODUCT ❑ COMMON NAME(/mm Hazardous Mafedals lnrenbrypage) CAS e(fmm Hazardous Materials lnrenrorypege) 4. HAZARDOUSWASTE(lndudea Used O/8 95 UNKNOYM HL TANK CONSTRUCTION TYPE OF TANK , SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ S. SINGLE WALL VATH INTERNAL BLADDER SYSTEM (CMkorroi(amonW ❑ 2, DOUBLEWALL EXTERIOR MEMBRANE LINER [3 95. UNKNOWN -❑ 4. SINGLE WALL IN A VAULT ❑99, OTHER TANK MATERIAL-pomary Mnk )K BARE STEEL ❑ 3. FIBERGLASS/PLASTIC ❑ 5. CONCRETE 095. UNKNOWN (Checkprndemomy) ❑ 2. STAINLESS STEEL ❑4. STEEL CLADWIFIBERGLASS ❑ B. FRP COMPATIBLE W1100%METHANOL ❑89. OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-asoono.q lank71 BARE STEEL ❑ 3. FIBERGLASS/PLASTIC ❑ 8. FRP COMPATIBLE WI100%METHANOL ❑95. UNKNOWN (Check one Rem ony) ❑ 2. STAINLESS STEEL ❑ 4. SrEELCLADWIFIBERGLASS ❑ 9. FRP NON-CORRODIBLE JACKET _ ❑99. OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL ❑ 5. CONCRETE TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑ 3. EPOKY LINING ❑ 5. GLASS LINING 095. UNKNOWM433 DATEINSTALLED OR COATING ❑ Z. pLKYO LINING ❑ 4. PHENOLIC LINING �e. UNLINED 099. OTHER (Forlocal uae on (Check.Ram on ) OTHER CORROSION ;[32. ;SACRIFICIAL;ANODE FACTUATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC 5. UNKNOWM 43! DATEINSTALLED PROTECTION IF APPLICABLEECTION ❑ 4. IMPRESSED CURRENT ❑99. OTHER (Forlocel uae only (Check oro item only) SPILL AND OVERFILL YEAR INSTALLED TYPE(Forlocal use only) OVERFILL PROTECTION EQUIPMENT:YFAR INSTALLED 1 , �I (Chock 0 that appy) ❑ 1. SPILLOONTAINMENT ❑ 1. ALARM _ ❑ 3. FILL TUBE SHUT OFF VALVE ❑ 2. DROPTUBE ❑ 2. BALL FLOAT ❑ 4. EXEMPT ❑ 3. STRIKER PLATE - I¢ TANK LEAN DETECTION. IF SINGLE WALL TANK Chat so thalap ): IF DOUBLE WALL TANK OR TANK WITH BLADDER(Check one demonl ❑ 1. VISUAL(E)(POSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY) ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ 6. VADOSEZONE ❑ 2. CONTINUOUS INTERSTITIAL MONITORING ❑ 3. CONTINUOUSATG ❑ T. GROUNDWATER ❑ 3. MANUALMONITORING ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR) ❑ S. TANK TESTING � ry-�� BIENNIAL TANK TESTING - 99. OTHER It-{p.[ V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED RAdO Y) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL? gallons ❑Yes Np oyd6 CUPAFORM(4199) Formerly SWRCB Foon B