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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 <br /> (Mo pages per tank) <br /> Page <br /> TYPEOFACTION LNEW SITE PERMIT ❑ C AMENDED PERMIT ❑ S. CHANGE OF INFORMATION) ❑ 0. TEMPORARY SITE CLOSURE <br /> (Check one item onW ❑ T. PERMANENTLYCLOSEO ON SITE <br /> ❑].RENEWAL PERMIT (SpeoY,heron-N,W i u a aHyl (Spealy tMrge-MIOW ms ole) ❑ S.TANK REMOVED 430 <br /> BUSINESS NAME(Same n FACILITY NAME or DSA-Oomg Bush...b) FACILITY ID F 1 <br /> /ACL FSC �v LL' <br /> LAO VA IN bIT (OpEOM9 �t p-�E"�� � EL <br /> I.TANK DESCRIPTION <br /> TANKIDa TANK MANUFACTURER COMPARTIv)I�F.CI T�.[I NQ&t0 Yes <br /> emmpanmNo <br /> �� m01a <br /> DATE INSTALLED(YFARYMO) TANK C�AP^ACITY IN GALLONS NUMBV%!iGMPARTMEN{SHEALTw <br /> dz J 6 v U .70, / Pit SERVICES 'l <br /> ADDITIONAL DESCRIPTION(FWtocal one OrM <br /> It.TANK CONTENTS <br /> TANK USE 432 PETROLEUM TYPE <br /> 1. MOTOR VEHICLE FVEL ta. REGULAR UNLEADED T11 EADED ❑ 5. JET FUEL <br /> plmarkaQ'gmple",Peopleum Type) ❑Is. PREMIUM UNLEADED IESEL ❑ 6.AVIATION FUEL <br /> ❑ 2. NOWFUELPETROLEUM le MIOGRAOEUNLEAOEO ASOHOL 099. OTHER <br /> ❑ ]. CHEMICAL PRODUCT COMMONNAME Moe Hazardpst Materials lnNWOWPage) DAS a(Spm Hazardous Ma",dale In~WgPage) <br /> ❑ 4. I RCOUSWASTE(lnclWea <br /> UaeC Oq <br /> 95 UNKNOV,b <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK ❑ L SINGLE WALL ❑ 1. SINGLE WALL WITH ❑ 5. SINGLE WALL VATH INTERNAL BUDDER SYSTEM <br /> (Cnec4 ar",i",m eNy) 2, DOUBLE WALL EXTERIOR MEMBRANE LINER ❑95. UNKNOWN <br /> ❑ 4. SINGLE WALL IN A VAULT ❑gg. OTHER <br /> TANKMATERIAL-pruna7Uo* 1, BARE STEEL ❑ 0. FIBERGIASSIPLASTIC ❑ 5. CONCRETE C9 UNKNOWN <br /> (Check.dam only) ❑ 2, STAINLESS STEEL ❑4. STEEL CLAOWIFIBERGLASS ❑ a. FRP COMPATIBLE W IW%METHANOL ❑99. OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-aa Bary Wk ❑ 1 SARE STEEL ]. FISERGLASSIPLASTIC ❑ 0. FRP COMPATIBLE W/100%METHANOL ❑95. UNKNOWN <br /> (Check one dem 0*) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAO VAFISERGLASS ❑ 9 FRP NON-CORRODIBLE JACKET ❑99. OTHER <br /> REINFORCED PLASTIC(FRP) 01 COATED STEEL <br /> ❑ 5. CONCRETE <br /> TANK INTERIOR LINING ❑ 1 RUBBER LINED ❑ ]. EPDXY LINING ❑ 5. GLASS LINING ❑95. UNKNOVM411 DATE INSTALLED <br /> OR COATING <br /> ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING ❑ B UNLINED ❑99. OTHER FPrlWal use on ) <br /> (Cnxk one dem only) <br /> OTHERCORROSION ❑ 1 MANUFACTURED CATHODIC ❑ 1. FIBERGLASS REINFORCED PLASTIC 095. UNKNOWN 43A DATEINSTALLEO <br /> PROTECTION IF APPLICABLE PROTECTION <br /> ❑ 4. IMPRESSED CURRENT ❑99. OTHER <br /> (Check one item aMy) ❑ 2. SACRIFICIAL ANODE (FWbcal usa anry) <br /> SPILL AND OVERFILL YEAR INSTALLED TYPE(FWIWai use oNy) OVERFILL PROTECTION EQUIPMENT.YEAR INSTALLED <br /> (Chat"" Nappw T SPILL CONTAINMENT 1.ALARM 1. FILL TUBE SHUT OFF VALVE <br /> Z. DROP TUBE ❑ 2. BALL FLOAT ❑ 4. EXEMPT <br /> ]. STRIKER PLATE <br /> IV.TANK LEAK DETECTION <br /> IF SINGLE WALL TANK I",ck aFNat IF DOUBLE WALL TANK OR TANK WITH BLADDER(CMck orw i",m o ): <br /> ❑ t, VISUAL(EXPOSED PORTION ONLY) ❑ S. MANOALTANKOAUGINGIMTG) ❑ 1. WSUAL(SINGLE WALL IN VAULT ONLY) <br /> 2. AUTOMATIC TANK GAUGING(ATG) ❑ 0. VADOSEZONE 2 CONTINUOUSINTERSTITIALMONITORING <br /> ❑ ]. CONTINUOUSATG ❑ T. GROVNDWATER ❑ ]. MANUALMONITORING <br /> ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR)• ❑ 6. TANKTESTING <br /> BIENNIAL TANK TESTING 099. OTHER <br /> V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PUCE <br /> ESTIMATED DATE LAST USED(YRMO/OAY) ESTIMATEOQUANTITYOFSUSSTANCEREMAINING 415 TANK FILLEOW1Tt INERT MATERIAL? <br /> pews ❑Yes ❑No <br /> CUPAFORM(4/99) - " Fotmedy SWRCB Folin B <br />