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L M � UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANKS-TANK PAGE 1 ( / Y -TYPE OF ACTION ❑I NEW SITE PERMIT ❑ 4 AMENDED PERMIT ®'5CHA*sr -----*r IATION ❑ 6 TEMPORARY SITE CLOSURE (Chxk as nem aur) _ _ _ -T ❑ 7 PERMANENTLY CLOSED ON S ❑ 3 RENEWAL PERMIT (Speri),mm-forloow woNy) (spedlynawn-fo.lowl ody) 8 TANK REMOVED 450 FACILITY ID: Cyt 1 BUSINESS NAME(s.mesPA//CnIfY NAbtE wDBA-Ibirg liu.iem.A.) 3 ��. LOCATION WITHIN Slgopuoo.0 al �- L TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local agency.) TANK IDN) 033 T,AANK UFACTURER 411 COMPARTMENTALIZED TANK Yes o 434 ^ I•YeJ',eomplgeam p.gefOr uftcpmp.rtmmt - DATE INSTALLED(YEAR/MO) 415 TANK CAPACITY IN GALLONS ' NUMBER OF COMPARTMENTS 07 O I 000 - 2 ADDITIONAL DESCRIPTION(POr tvl uw wly) - 404 U.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 If'1. MOTOR VEHICLE FUEL ❑la REGULAR UNLEADED [12. LEADED ❑5. JET FUEL gf.tw.%V1°e P�T' ) B lb. PRB41UM UNLEADED ❑3. DIESEL ❑6. AVIATION FUEL ❑2. NON-FUEL PETROLEUM ❑lc. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER ❑3. CHEMICAL PRODUCT COMMON NAME (6om Bamrdom m"w.Imev.Ory pw) �( CAS#(loan F4ardau MuriJ.Ivvm.ory pye) 44Z ❑4. HAZARDOUS WASTE ❑95.UNKNOWN 111. TANK CONSTRUCTION TYPE OF TANK 1. SINGLE WALL 03. SINGLE WALL WITH 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM N) (C'heh-n.m Orly) EXTERIOR MEMBRANE LDYER ❑95. UNKNOWN 0 2. DOUBLE WALL [34. SIGNLE WALL IN VAULT ❑99. OTHER ' TANK MATERIAL.-Ki.ry uek Q 1. BARE STEEL 19 3. FIRFRGLASS/PLASTIC 0 5. CONCRETE 0 95. UNKNOWN 111 (C0e 1 on Num Orly) ❑2. STAINLESS STEEL [34. STEEL CLAD W/FIBERGLASS ❑S. FRP COMPTIBLE W1100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL.-mroudny uat 0 1. BARE STEEL 23. FIBERGLASS/PLASTIC 5. CONCRETE 95. UNKNOWN MS (Cbe Y om ium mty) ❑2. STAINLESS STEEL [14. STEEL CLAD W/FMERGLASS ❑8. FRP COMPTIBLE W/100%METHANOL ❑W OTHER REINFORCED PLASTIC(FRP) ❑10.COATED STEEL ❑S. CONCRETE TANK INTERIOR LINING 0 1.RUBBER LINED 3.EPDXY LINING 5.GLASS LINING 95.UNKNOWN 446 DATE INSTALLED N7 OR COATING ❑2 ALKYD LINING 0 4 PHENNOLIC LINING E16 UNLINED ❑99 OTHER (Cbvt am irw my) (Fw bml m oYy) OTHER CORROSION ❑1 MANUFACTURED CATHODIC ❑3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN 44F DATE INSTALLED II9 PROTECTION IF APPLICABLE PROTECTION ❑4 IMPRESSED CURRENT ❑99 OTHER (Chert om b®only) ❑2 SACRIFICIAL ANODE (FO hal""O°Is') SPILL AND OVERFILL YEAR INSTALLED 450 TYPE(ban.ody) 4s1 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Cbeet A 1b ggly) O'I SPILL CONTAD&HNT .-. ❑1 ALARM ®3 FILL TUBE SHUT OFF VALVE 2 DROP TUBE ❑2 BALL FLOAT. ❑4 EXEMPT Q 3 STRIKER PLATE IV.TANK LEAK DETECTION(A dm pfa a W m 060 pwp SWI W nbmtld orb.b RVMy) IF SINGLE WALL TANK(Chert dl mr.A*) 433 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 (Cbrt.s awry) ❑ 1 VISUAL(E)IFOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MTG) ❑1 VISUAL(SINGLE WALL IN VAULT ONLY) ❑2 AUTOMATIC TANK GAUGING(ATG) ❑b VADOSE ZONE ❑2 CONTINUOUS INTERSTITIAL MONITORING ❑3 CONTINUOUS ATG ❑7 GROUNDWATER ❑3 MANUAL MONITORING ❑4 STATISTICAL INVENTORY RECONCILIATION ❑8 TANK TESTING (SIR) BIENNIAL TANK TESTING . ❑99 OTHER IV.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USIDIYR/MO/DAY) 4S5 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH VERT MATE7UAL7 �' /5% '� gallons ❑Yes No n { oaf a`/D t l��) l L✓� r