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UNIFIED PROCx,RAM ISONSOLIDATED FOR O� J �T �i'ANKS UNDERGROUND STORAGE TANKS-TANK 1 (two pages per tank) U Page _ of �" ❑ 8.TEMPORARY SITE CLOSURE TYPE OF ACTION ./c�i.NEW SITE PERMIT- ❑A.AMENDED PERMIT ❑ 5. CHANGE OF INFORMATION) ❑ 7 PERMANENTLY CLOSED ON SITE (Check one item only) _ \ . 03.RENEWAL PERMIT (Specify reason-lorlocal use only) (Speciry change-for local use only) ❑ B.TANK REMOVED 430 FACILITY ID#-- 1 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) a It LOCATION WITHIN SI (Op6onaq 431 1.TANK DESCRIPTION TANKMANUFACTURER COMPARTMENTALIZED TANK ❑ Yes No T9tJK ID# J 7 / � � �� II'Yes',complete one Page for each compartment. 7z CAPACITY IN GALLONS NUMBER OF COMPARTMENTS TANK DATE INSTALLED(YEAR/MO) / ADDITIONAL DESCRIPTION(Forlocal use only) II.TANK CONTENTS TANK USE 432 PETROLEUM TYPE ❑ 5.JET FUEL ❑ []'I.MOTOR VEHICLE FUEL ❑1a. REGULAR UNLEADED 2. LEADED ❑ 6.AVIATION FUEL (Ifmarked,complete Petroleum Type) ❑1b. PREMIUM UNLEADED ❑ 3. DIESEL ❑ 2. NON-FUEL PETROLEUM ❑1c. MIDGRADE UNLEADED ❑ 4.GASOHOL ❑99. OTHER --3.CHEMICAL PRODUCT MON NAME(fCAS#{from Hazardous Matenals Inventory page) (from Hazardous Matenals fnvenfory page)� " ❑ 4. HAZARDOUS WASTE(Incudes Used Oiq 9 UNKNOWN TIL TANK CONSTRUCTION TYPE OF TANK 01. SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM EXTERIOR MEMBRANE LINER ❑95. UNKNOWN (Check one item only) E32. DOUBLE WALL ❑ 4. SINGLE WALL IN A VAULT ❑99. OTHER TANK MATERIAL-primary tank ❑ 3. FIBERGLASS/PLASTIC ❑ 5.CONCRETE ❑95. UNKNOWN _0 . BARE STEEL (Check one item only) ❑ 2. STAINLESS STEEL [:14. STEEL CLAD W/FIBERGLASS ❑ B. FRP COMPATIBLE W/700%METHANOL ❑89. OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary tank ❑ 1 BARE STEEL ❑ 3. FIBERGLASS/PLASTIC ❑ S. FRP COMPATIBLE W/100%METHANOL ❑95.UNKNOWN (Check one item only) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC(FRP) ❑ 9. FRP NON-CORRODIBLE JACKET ❑99.OTHER [110.COATED STEEL ❑ 5. CONCRETE DATE INSTALLED TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ S.S. GLASS LINING ❑95.UNKNOWN433 OR COATING ❑ q. PHENOLIC LINING 4.36 -+ o UNLINED ❑99.OTHER ❑ 2.ALKYD LINING \ (For local use only) (Check one item onl) DATE INSTALLED OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC 95. UNKNOWN 434 PROTECTION IF APPLICABLE PROTECTION ❑99. OTHER , ❑ 4.IMPRESSED CURRENT (Forlocal use only) (Check one item only) ❑ 2. SACRIFICIAL ANODE SPILL AND OVERFILL - YEAR INSTALLED TYPE(For local use only) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED (Check all that apply) ❑ 1 SPILL CONTAINMENT.-�Ll /.� ❑ 1.ALARM ❑ 3. FILL TUBE SHUT OFF VALVE ❑ 2. DROP TUBE ❑ 2. BALL FLOAT ❑4. EXEMPT ❑ 3. STRIKER PLATE v,s IV.TANK LEAK DETECTION. Y IF SINGLEWALLTANK Check all that e f): IF DOUBLE WALL TANK OR TANK WITH BLADDER Check one item ant ❑ 1, VISUAL(EXPOSED PORTION ONLY) ❑ S. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY) ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ 8. VADOSE ZONE ❑ 2. CONTINUOUS INTERSTITIAL MONITORING ❑ 3. CONTINUOUS ATG. ❑ 7. GROUNDWATER ❑ 3. MANUAL MONITORING ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR)+ ❑ 8. TANKTESTING BIENNIAL TANK TESTING ❑99. OTHER V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL? gallons ❑Yes ❑No I` Formerly SWRCB Form B CUPAFORM(4/99)