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UNIFIED PROGRAM CONSOLIDATED FORM d(two ANKS UNDERGROUND STORAGE TANKS -TANK PAGE 1 es per tank) Page _ of TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 4. AMENDED PERMIT ❑ 5. CHANGE OF INFORMATION) ❑ 8. TEMPORARY SITE CLOSURE (Check one dem on;y) ❑ 7. PERMANENTLY CLOSED ON SITE ❑3.RENEWAL PERMIT (Specify i9ason-for local use orW) (Specify change-for IxM use only) ❑ 8. TANK REMOVED 430 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) FACILITY ID# 1 LOCATION WITHIN SITE(Optionap 4 1 02 I.TANK DESCRIPTION rrtt�e TANK ID# TANK MANUFACTURER COMPARTMENTALIZED TANK ❑ Yes ps No c� o fir' If'Y63,complete one page for each compartment. DATE I71W T LED(YEAR/MO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS 11 1.2, 00 0 �- ADDITI NAL DESCRIPTION(Forlocal use only) II.TANK CONTENTS TANK USE 432 PETROLEUM TYPE 1. MOTOR VEHICLE FUEL El la REGULAR UNLEADED D 2. LEADED El 5JET FUEL . ff marked,complete Petroleum Type) / o PREMIUM UNLEADED ❑ 3. DIESEL ❑ 6. AVIATION FUEL [12. NON-FUEL PETROLEUM 0,cMIDGRADE UNLEADED ❑ 4.GASOHOL ❑99 OTHER ❑ 3. CHEMICAL PRODUCT # tiom Hazardous Materials Inventory page) COMMON NAME(from Hazardous Malaria/s Inventory page) CAS ( ❑ 4. HAZARDOUS WASTE(Includes Used Dip 95. KNQWN Y) Ill.TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM EXTERIOR MEMBRANE LINER [196. UNKNOWN (Check one item only) �2. DOUBLE WALL ❑ 4. SINGLE WALL IN A VAULT ❑gg, OTHER TANK MATERIAL-primary tank 1 BARE STEEL ❑ 3. FIBERGLASS/PLASTIC ❑ 5. CONCRETE ❑95. UNKNOWN (Check one item only) ❑ 2. STAINLESS STEEL ❑4. STEEL CLAD WIFIBERGLASS ❑ B. FRP COMPATIBLE W/100%METHANOL ❑99. OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary tank ❑ 1 BARE STEEL ❑ 3. FIBERGLASS/PLASTIC ❑ 8. FRP COMPATIBLE W/100%METHANOL ❑95. UNKNOWN (Check one item only) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD W/FIBERGLASS ❑ 9. FRP NON-CORRODIBLE JACKET ❑99.OTHER REINFORCED PLASTIC(FRP) X10 COATED STEEL ❑ 5.CONCRETE TANK INTERIOR LINING ❑ 1, RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING ❑95. UNKNOWN433 DATE INSTALLED OR COATING eAn.� ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING al 8 UNLINED 1199. OTHER (For local use only) (Check one dem only) DATE INSTALLED OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC 1w.5. UNKNOWN 434 PROTECTION IF APPLICABLE PROTECTION ❑ 4. IMPRESSED CURRENT t999. OTHER(f0g(2E]2 ST L (For local use only) (Check one item only) ❑ 2. SACRIFICIAL ANODE PE(For Iota - YEAR INSTALLED TYl use only) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED SPILL AND OVERFILL (Check all that apply) ® 1 SPILL CONTAINMENT ❑ 1. ALARM M3. FILL TUBE SHUT OFF VALVE 16 2, DROP TUBE ❑ 2. BALL FLOAT ❑ 4. EXEMPT I�3. STRIKER PLATE IV.TANK LEAK DETECTION 1F SINGLE WALL TANK Check au that apply) IF DOUBLE WALL TANK OR TANK WITH BLADDER(Check one item only): ❑ 1, VISUAL(EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING(MTG) ❑t1 1. VISUAL(SINGLE WALL IN VAULT ONLY) ❑ 2. AUTOMATIC TANK GAUGING(ATG) [1 6. VADOSE ZONE A 2. CONTINUOUS INTERSTITIAL MONITORING ❑ 3. CONTINUOUS ATG ❑ 7. GROUNDWATER ❑ 3. MANUAL MONITORING ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR)• ❑ 8. TANK TESTING 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 1 TANK FILLED WITH INERT MATERIAL? gallons ❑Yes ❑No CUPAFORM(4/99) Formerly SWRCB Form B