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ti� dft &,�! <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 1 <br /> (two pages per tank) <br /> Page _ of <br /> TYPE OF ACTION 1.NEW SITE PERMIT ❑ 4. AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION) ❑ 6. TEMPORARY SITE CLOSURE <br /> (Check one Rem only) ❑ 7. PERMANENTLY CLOSED ON SITE <br /> ❑3.RENEWAL PERMIT (Specify reason-for local use only) (Specify change-for local use only) ❑ 8. TANK REMOVED 430 <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) FACILITY ID A 1 <br /> LOCATION WITHIN SITE(Optioneq 431 <br /> I.TANK DESCRIPTION <br /> TANK ID a TANK MANUFACTURER COMPARTMENTALIZED TANK Yes ❑ No <br /> If*Yes*,complete one page for each compartment. <br /> her>���-lv r'�u�����rr::l✓:-L i�- <br /> DATE INSTALLED(YEAR/MO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> ADDITIONAL DESCRIPTION(For local use only) <br /> R.TANK CONTENTS <br /> TANK USE 432 PETROLEUM TYPE <br /> 1 MOTOR VEHICLE FUEL ❑la REGULAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL <br /> (If marked,complete Petroleum Type) Ertb. PREMIUM UNLEADED ❑ 3. DIESEL ❑ 6 AVIATION FUEL <br /> ❑ 2. NON-FUEL PETROLEUM ❑1. MIDGRADE UNLEADED ❑ 4. GASOHOL ❑99 OTHER <br /> ❑ 3. CHEMICAL PRODUCT CAS a from Hazardous Materials Inventory page) <br /> COMMON NAME(from,Hazardous Materials Inventory page) <br /> ❑ 4. HAZARDOUS WASTE(Includes <br /> Used Oil) <br /> 95, UjSN <br /> 111.TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1. SINGLE WALL El3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> M/ <br /> (Check one item only) 2. DOUBLE WALL EXTERIOR MEMBRANE LINER ❑95. UNKNOWN <br /> ❑ 4. SINGLE WALL IN A VAULT ❑99 OTHER <br /> TANK MATERIAL-primary tank ❑ 1 BARE STEEL �❑:1 3. FIBERGLASS/PLASTIC ❑ 5. CONCRETE ❑95. UNKNOWN <br /> (Check one item only) ❑ 2 STAINLESS STEEL La 4. STEEL CLAD W/FIBERGLASS ❑ 8. FRP COMPATIBLE W/100%METHANOL ❑99. OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-secondary tank ❑ 1, BARE STEELr❑y 3. FIBERGLASS/PLASTIC C18. FRP COMPATIBLE W/100%METHANOL ❑95. UNKNOWN <br /> (Check one item only) ❑ 2. STAINLESS STEEL Id 4. STEEL CIAO WIFIBERGLASS ❑ 9 FRP NON-CORRODIBLE JACKET ❑99. OTHER <br /> REINFORCED PLASTIC(FRP) ❑10 COATED STEEL <br /> ❑ 5. CONCRETE <br /> TANK INTERIOR LINING ❑ 1. RUBBER LINED C13. EPDXY LINING ❑ 5. GLASS LINING ❑95. UNKNOWN433 DATE INSTALLED <br /> OR COATING �{ <br /> ❑ 2. ALKYD LINING El 4, PHENOLIC LINING uJ 6 UNLINED ❑99. OTHER <br /> (Check one item only) ATE cal use only) <br /> D <br /> OTHER CORROSION C1TURED CATHODIC 113. FIBERGLASS REINFORCED PLASTIC y1 <br /> 1. MANUFACTURED ❑95 UNKNOWN 4 <br /> PROTECTION IF APPLICABLE PROTECTION [01DATE INSTALLED <br /> /. IMPRESSED CURRENT ❑99. OTHER <br /> (Check one item only) ❑ 2. SACRIFICIAL ANODE (For local use only) <br /> SPILL AND OVERFILL YEAR INSTALLED TYPE(For local usselo�nly) OVERFILL PROTECTION EQUIPMENT.YEAR INSTALLED <br /> (Check aR that apply) 1 SPILL CONTAINMENT )/R 1'7a'�W I'wI ❑ 1.ALARM ❑ 3. FILL TUBE SHUT OFF VALVE <br /> Lp <br /> 2. DROP TUBE ol W2. BALL FLOAT ❑ 4. EXEMPT <br /> [�3. STRIKER PLATE 00 <br /> IV. TANK LEAK DETECTION <br /> IF SINGLE WALL TANK Check aR that app <br /> 1= IF DOUBLE WALL TANK OR TANK WITH BLADDER(Check one item only): <br /> ❑ 1, VISUAL(EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ 6. VADOSE ZONE ❑ 2. CONTINUOUS INTERSTITIAL MONITORING <br /> ❑ 3. CONTINUOUS ATG ❑ 7. GROUNDWATER ❑ 3. MANUAL MONITORING <br /> ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR) ❑ 8. TANK TESTING <br /> BIENNIAL TANK TESTING ❑99. OTHER <br /> V.TANK CLOSURE INFORMATION!PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YR/MO/DAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 1 TANK FILLED WITH INERT MATERIAL? <br /> gallons ❑Yes ❑No <br /> CUPAFORM(4/99) Formerly SWRCB Form B <br />