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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 7 <br /> (Mo Cages pe.tank) <br /> Page _ of _ <br /> TYPE OF ACTON ❑1.NEW SITE PERMIT 0 A. AMENDED PERMIT 0 S. CHANGE OF INFORMATION) 0 a. TEMPORARY SITE CLOSURE <br /> (Lhrk Pm Aam Dory) 0 ?. PERMANENTLY CLOSED ON SITE <br /> ❑3.RENEWAL PERMIT (Spwiyeaws.-hr Acal ufe plky) (Sprig chops-krlwal mep w ❑ a. TANK REMOVED Ago <br /> BUSINESS NAME(Samoa FACILITY NAME or DBA-DoN Bwinasa ASI FACILITY 101 1 <br /> VIP, C( V-7%C .Cl .> <br /> L rlOr+a l <br /> SITE pp rQC 1 <br /> /Z/< �/� �/ C k_/(S <br /> 6 , C41 <br /> LLI� I.TANK DESCRIPTION <br /> TANK 10 I TANK MANUFACTURER COMPARTMENTALIZED TANK Va+ ❑ No <br /> J�p Q r If-Y.3',WMPIeI50"Page W OM f PaM10nL <br /> PATE INSTALLED(YPARRA0) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> ADDITIONAL DESCRIPTION(Fwfcal uae pNy) <br /> IL TANK CONTENTS <br /> TANK USE 402 PETROLEUM TYPE 11[ T U4 2 <br /> 1. MOTOR VEHICLE FUEL 0 L REGULAR UNLEADED 0 a1 2. LEADED Y EL <br /> (RmaAtC,c.mpbte PefMeum Type) 10. PREMIUM UNLEADED 0 5. DIESEL °35,V T }{EALTN <br /> ❑ 2. NOWFUEL PETROLEUM ❑lc. MIDGRADEUNLEACED 0 A. GASOHOL <br /> ❑ 2. CHEMICALPRODUCTqlp <br /> m atalnl/nwnrory pagq <br /> ❑ A. HA2ARDOUSWASTE(IwJWta COMMON NAME(parr H+palUpua Mamma.l tpryPa9a) <br /> tw U.&4 Oq <br /> nes UNKNOWN <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1. SINGLE WALL ❑ D. SINGLE WALL WITH 0 5. SINGLE WALL WITH INTERNAL BIADDER SYSTEM <br /> (Cnrkm+Nempmy) 2, DOUBLE WALL EKNGLE WALL IMEMBRN <br /> A LINER 095. UNKNOWN <br /> ❑ A. SINGLE WALL INAVAULT 0OTHER <br /> TANK MATERIAL p4mwy tank 1, BARE STEEL ❑ 5. FIBERGLASS I PLASTIC 05. CONCRETE 095. UNKNOWN <br /> (CMkme Kem PMl7 0 2. STAINLESS STEEL 04. STEEL CLAD VATIBERGLASS 0 B. FRP COMPATIBLE W/100%METHANOL 099. OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL aarnMary Mnk 0 1 BARE STEEL 5. FIBERGLASS/PLASTIC ❑ S. FRP COMPATIBLE WlIW%METHANOL 095. UNKNOWN <br /> (Check.Ram aMy) 0 2, STAINLESS STEEL 0 A. STEEL CLADWIFlBERGIASS 0 9 FRP NON-CORRODIBLE JACKET 099. OTHER <br /> REINFORCED PLASTIC(FRP) 010 COATEDSTEEL <br /> ❑ 5. CONCRETE <br /> TANK INTERIOR LINING 0 1, RUBBER LINED 0 5. EPDXY LINING 0 5. GLASS LINING 0 95, UNKNOWN433 DATE INSTALLED <br /> ORCOATNG <br /> ❑ 2. ALKYD LINING ❑ A. PHENOLIC LINING ❑a. UNLINED 0 99, OTHER Fwlwal mt pnl) <br /> (Ch+ck mu more P ) <br /> DATE INSTALLED <br /> OTHER CORROSION 0 1 MANUFACTURED CATHODIC 0 0, FIBERGLASS REINFORCED PLASTIC 095. UNKNOWN e2A <br /> PROTECTION IF APPLICABLE PROTECTION <br /> ❑ t IMPRESSED CURRENT 089. OTHER (Fwbcal ma pny) <br /> (Check oM 4am+my) ❑ 1 SACRIFICIALANODE <br /> SPILL AND OVERFILL YEAR INSTALLED TYPE(Fpr Anal use pny) OVERFILL PROTECTION EQUIPMENT.YEAR INSTALLED <br /> (LMckslmaapply) 1SPRL CONTAINMENT 7 1.ALARM S. FILL TUBE SHUT OFF VALVE <br /> 2. DROPTUSE 0 2. BALLFLGAT 0 4. EXEMPT <br /> J. STRIKER PLATE <br /> IV. TANK LEAK DETECTION <br /> IF SINGLE WALL TANK CMck as WE APPW IF DOUBLE WALL TANK OR TANK WITH BLADDER pm Atm ): <br /> ❑ 1, VISUAL(E%POSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGINGiMTG) 0 1. VISUAL(SINGIE WALL IN VAULT ONLY) <br /> 2. AUTOMATIC TANK GAUGING(ATG) OIL VADOSEZONE Im 2. CONTINUOUS INTERSTITIAL MONITORING <br /> 0 0. CONTINUOUSATG 0 T. GROUNDWATER 0 5. MANUALMONITORING <br /> 0 A. STATISTICALINVENTORY RECONCILIATION(SIR)- 0 a. TANKTESTING <br /> BIENNIAL TANK TESTING Ops, OTHER <br /> V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YRIMOIDAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 405 TANK FILLED WITH INERT MATERIAL? <br /> ga9ms 0 Yea ON. J <br /> CUPAFORM(4/99) .,_ Foymedy SWRCB Form B <br />