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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 1 (t1w pages per tank) Page _ of TYPE OF ACTION 0 1.NEW SITE PERMIT ❑ 4. AMENDED PERMIT ❑ 5. CHANGE OF INFORMATION) ❑ S. TEMPORARY SITE CLOSURE (Check one item only) C1❑3.RENEWAL PERMIT 7. PERMANENTLY CLOSED ON SITE (Specify reason-for local use only) (Specify change-for local use oW ❑ S. TANK REMOVED 430 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) FACILITY 10 eIJNTTRD GAS 1 LOCATION WITHIN SITE(Optional) 431 I.TANK DESCRIPTION TANK ID a 6l J �� TANK MANUFACTURER COMPARTMENTALIZED TANK ClYes �{No SCO If-Yes',complete one page for earn compartment. DATE INSTALLED(YEAR/MO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS 10-99 20,000 ADDITIONAL DESCRIPTION(For local use only) If.TANK CONTENTS TANK USE 432ay�� PETROLEUM TYPE ��77 6j,&.%J gTOR VEHICLE FUEL :0 1a. REGULAR UNLEADED {y 2. LEADED ❑ 5. JET FUEL (If ma4a,complete Petroleum Type) ❑1E. PREMIUM UNLEADED ❑ 3. DIESEL ❑ 6. AVIATION FUEL ❑ 2. NON-FUEL PETROLEUM ❑1c MIDGRADE UNLEADED ❑ 4. GASOHOL ❑99. OTHER ❑ 3. CHEMICAL PRODUCT C3 4. HAZARDOUS WASTE(Includes COMMON NAME(from Hazardous Materials Inventory page) CAS a(from Hazardous Malenals In antory page) Used Oil) C3 5oUNKNOWN 111.TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM (Check one item only) [R 2. DOUBLE WALL EXTERIOR MEMBRANE LINER ❑95. UNKNOWN ❑ 4. SINGLE WALL IN A VAULT ❑99. OTHER TANK MATERIAL-primary tank ❑ 1 BARE STEEL ❑ 3. FIBERGLASS t PLASTIC ❑ 5. CONCRETE ❑95. UNKNOWN (Check one item only) ❑ 2. STAINLESS STEEL JD 4. STEEL CLAD WIFIBERGLASS ❑ S. 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) ❑10. COATED STEEL ❑ 5. CONCRETE TANK INTERIOR LINING C3 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ 5.GLASS LINING C195. UNKNOWN433 DATE INSTALLED OR COATING ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING ❑ 6. UNLINED ❑99. OTHER (Check one,tem only) (For local use only) OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC J. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN 434 DATE INSTALLED PROTECTION IF APPLICABLE PROTECTION ❑ 4, IMPRESSED CURRENT ❑99. OTHER (Check one item only) ❑ 2. SACRIFICIAL ANODE (For local use only) SPILL AND OVERFILL YEAR INSTALLEDTYPE(For local use only) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED (Check ail that appy) 1=7 1 SPILL CONTAINMENT 1j] 1. ALARM ] 3. FILL TUBE SHUT OFF VALVE 2. DROP TUBE 2. BALL FLOAT ❑ 4. EXEMPT yy 3. STRIKER PLATE IV. TANK LEAK DETECTION IF SINGLE WALL TANK(Cheek a4 that appy): IF DOUBLE WALL TANK OR TANK WITH BLADDER(Check one item onty): ❑ 1. VISUAL(EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY) ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ 6. VADOSE ZONE 5' 2 CONTINUOUS INTERSTITIAL MONITORING ❑ J. 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 TANK FILLED WITH INERT MATERIAL? gallons ❑Yes ❑No V ' CUPAFORM(4199) Formerly SVVRCB Form B