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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 1 I (two pages per tank) Page _ of _ TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 4. AMENCED PERMIT ❑ 5. CHANGE OF INFORMATION) ❑ 8. TEMPORARY SITE CLOSURE (Crack one item only) ❑ 7. PERMANENTLY CLOSED ON SITE ❑3.RENEWAL PERMIT (SPecriY reason•forlocal use only) (Specilychenge-lorlo W use only) ❑ 8. TANK REMOVED 430 BUSINESS NAME(Same aLFACILITY r DBA-Doing Business Aa) FACILITY IDL A ON WITHIN SITE( 431�J ,f?,D 1 z• r . , 1.TANK DESCRIPTION TANK ID# TANK MANUFACTURER COMPARTMENTALIZED TANK ❑ Yes No U If'Yes',complete one page for each compartment. Yom._ (!J DATE IN TALLED(YEAR/MO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS `Z 'l I 700 ADDITIONAL DESCRIPTION(Forlocal use only) it..TANK CONTENTS TANK USE 432 PETROLEUM TYPE 1. MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED E] 2. LEADED ❑ 5. JET FUEL (If marked,complete Petroleum Type) ❑16. PREMIUM UNLEADED *3 DIESEL ❑ 8. AVIATION FUEL ❑ 2. NON-FUEL PETROLEUM [Ile. MIDGRADE UNLEADED ❑ 4. GASOHOL ❑99. OTHER ❑ 3. CHEMICAL PRODUCT COMMON NAME(from Hazardous Materials Inventory page) CAS#(from Hazardous Materials Inventory page) ❑ 4. HAZARDOUS WASTE(Includes CIO Used Oil) :NE6 -`u E` �J III.TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM EXTERIOR MEMBRANE LINER ❑95. UNKNOWN (Check one item only) 2. DOUBLE WALL o❑ 4. SINGLE WALL IN A VAULT ❑99. OTHER TANK MATERIAL•primary tank �1 BARE STEEL ❑ 3. FIBERGLASS/PLASTIC ❑ 5 CONCRETE ❑95. UNKNOWN (Check one item only) ❑ 2. STAINLESS STEEL ❑4 EL CLAD D PLASTIC( FRSs ❑ 8. FRP COMPATIBLE W/100%METHANOL ❑99. OTHER RE TANK MATERIAL-secondary tank ,r[1 BARE STEEL ❑ 3. FIBERGLASS I PLASTIC ❑ 8. FRP COMPATIBLE W/100%METHANOL ❑95. UNKNOWN "R ❑ 4. STEEL CLAD W/FIBERGLASS Cl P NON-CORROOIBLE JACKET ❑99. OTHER (Check one item only) ❑ 2. STAINLESS STEEL v�� REINFORCED PLASTIC(FRP) DATED STEEL 1 ❑ 5 CONCRETE DATE INSTALLED TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ 5 GLASS LINING ❑95. UNKNOWN433 OR COATING ❑ 2. ALKYD LINING ❑ 4 PHENOLIC LINING 8. UNLINED ❑99. OTHER (For local use only) (Check one item only) DATE INSTALLED OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC x.{95. UNKNOWN 434 PROTECTION IF APPLICABLE PROTECTION 009. OTHER ❑ 4. IMPRESSED CURRENT (For local use only) (Check one Nem only) ❑ 2. SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED TYPE(For local use only) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED (Check aN that apply) 'd�1 1 SPILL CONTAINMENT ❑ 1. ALARM IQ 3. FILL TUBE SHUT OFF VALVE IdN 2. DROP TUBE El 2. BALL FLOAT ❑ 4. EXEMPT 16t 3. STRIKER PLATE IV. TANK LEAK DETECTION IF SINGLE WALL TANK Check all that apply): IF DOUBLE WALL TANK OR TANK WITH BLADDER(Check one item onl): ❑ 1, VISUAL(EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING(MTG) [3 1. VISUAL(SINGLE WALL IN VAULT ONLY) I ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ 8. 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 Formerly SWRCB Form B CUPAFORM(4199)