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1 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 <br /> (two pages per lank) <br /> Page of _ <br /> TYPE OF ACTION 111.NEW SITE PERMIT 11 4. AMENDED PERMIT 5. CHANGE OF INFORMATION) ❑ 8. TEMPORARY SITE CLOSURE <br /> (Check one Tem only) <br /> ❑ ). PERMANENTLY CLOSED ON SITE <br /> D 3.RENEWAL PERMIT (Spedlymason-lorkcel use only) (Spft*charge-forkKN use only) D 8. TANK REMOVED 430 (/ <br /> BUSINESS NAME(Same as FACILITY NAME of DBA- Businaaa Aa) FACILITY IDM 1 <br /> GF1�Ts )q <br /> LOCATION WITHIN SITE(Opha lJ 431 <br /> sLl-s fru-e e,Il 5oao <br /> I.TANK DESCRIPTION <br /> TANK ID N TANK MANUFACTURER <br /> COMPARTMENTALIZED TANK ❑ Yes No <br /> IPVea',complete one page for eadl mmpanm nt. <br /> DATE INSTALLED((Y.EAARIAoO�)1 TANK CAPACITY <br /> YIIN GALLONS NUMBER OF COMPARTMENTS <br /> ADDITIONAL DESCRIPTION(Forrocal me omy) <br /> 11.TANK CONTENTS <br /> TANK USE 432 PETROLEUM TYPE <br /> 1. MOTOR VEHICLE FUEL 111a. REGULAR UNLEADED . LEADED D 5. JET FUEL <br /> (I dled,complete Permleum Type) 1b. PREMIUM UNLEADED 11 3. DIESEL D 6 AVIATION FUEL <br /> 11 2. NON-FUEL PETROLEUM U U. MIDGRADEUNLEADED D 4, GASOHOL 1199. OTHER <br /> 11 3. CHEMICAL PRODUCT <br /> 114. IUZARDOUS WASTE(Ir¢Iutles COMMON NAME(hem Hu.mA a Marseille Inwnforypage) CAS M(boon HazeNom Mefeeals Inwnrorypape) <br /> Used 0ko <br /> 0 95 UNKNOWN <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK 1. SINGLE WALL D 3. SINGLEWALLYATH 11 5, SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> (Check one lhm only) ❑ 2. DOUBLE WALL EXTERIOR MEMBRANE LINER 095, UNKNOWN <br /> 11 4. SINGLE WALL IN A VAULT [199 OTHER <br /> TANK MATERIAL-primary ark xBARESTEEL 03, FIBERGLASS I PLASTIC D 5, CONCRETE 095. UNKNOWN <br /> (Check one item only) 112_ STAINLESS STEEL 04. STEEL CLAD WIFIBERGUSS 118. FRP COMPATIBLE W110%METHANOL 099. OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL secondary ank 11 1 eARESTEEL ❑ 3. FIBERGLASS I PLASTID D B. FRP COMPATIBLE W1100%METHANOL 5. UNKNOWN <br /> (Check one item only) D 2, STAINLESS STEEL ❑ 4. STEEL CLAD WIFIBERGUSS 11 9. FRP NON-CORRODIBLE JACKET 1189. OTHER <br /> REINFORCED PLASTIC(FRP) U10, COATED STEEL <br /> 11 5. CONCRETE <br /> TANK INTERIOR LININGDATE INSTALLED <br /> OR COATING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. CUSS LINING ❑85. UNKNONN433 <br /> ❑ 2. ALKYD LINING D 4. PHENOLIC LINING xe UNLINED 1189. OTHER <br /> CheckowiMmon ) Forbceluseon ) <br /> OTHER CORROSION D 1. MANUFACTURED CATHODIC D 3, FIBERGLASS REINFORCED PLASTIC ri* UNKNOWN 434 DATEINSTALLED <br /> PROTECTION IF APPLICABLE PROTECTION <br /> ❑ 4. IMPRESSED CURRENT ❑BB. OTHER <br /> (Check one item only) ❑ 2. SACRIFICIAL ANODE I lForlocal oils only) <br /> SPILL AND OVERFILL VIA <br /> YEAR INSTALLED TYPE(Forlocalueeomy) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (Check0fifu apply) Cl 1. SPILL CONTAINMENT D 1.ALARM ❑ 3. FILL TUBE SHUT OFF VALVE <br /> D 2. DROP TUBE ❑ 2. BALL FLOAT ❑ 4. EXEMPT <br /> ❑ 3. STRIKER PLATE <br /> IV. TANK LEAK DETECTION <br /> IF SINGLE WALL TANK Check all that apply): IF DOUBLE WALL TANK OR TANK WITH BLADDER(Check one ihm only). <br /> 11 1. VISUAL(EXPOSED PORTION ONLY) 11 5. MANUAL TANK GAUGING(MTG) D 1. VISUAL(SINGLE WALLIN VAULT ONLY) <br /> 11 2. AUTOMATIC TANK GAUGING(ATG) 11 B. VADOSEZONE 11 2. CONTINUOUS INTERSTITIAL MONITORING <br /> D 3. CONTINUOUSATG D T. GROUNDWATER 11 3. MANUAL MONITORING <br /> D 4. STATISTICAL INVENTORY RECONCILIATION(SIR) D 8. TANKTESTIN--G11 <br /> BIENNIAL TANK TESTING 9_ OTHER IU O13/G <br /> V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YRMCIDAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH I NERT MATERIAL? <br /> gallons <br /> ❑Vas No <br /> .F D A-00 /as'V <br /> ������ D <br /> CUPAFORM(4199) • • Founedy SWRCB Form B <br /> ,,s A �l3/� <br />