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FROM . (THU) JUN 10 2004 12 ' -,/ST-A 7 o. 50 p 4 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS Q�a <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 � <br /> (twv pages per tank) <br /> P.Se-'IL of <br /> TYPE OF ACTION ❑1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT Q 5 CHANGE OF INFORMATION Cl 6 TEMPORARY SITE CLOSURE \ <br /> (CtWAOWFt=aab) ❑ 7 P17RMANENTLY CLOS ED ON SITE <br /> ❑ 3 RENEWALPERMIT (Specdy_-fabe4lweo,*) (spe*nma,-rerloalwt:4nly) ❑ 8 TANKREMOVED <br /> BUSINESS NAME,(-.-.9PACMMMAM-I)B•-D,e6e,�As) FACILITY ID, t <br /> 3 <br /> 1��� �� Vr <br /> I � EL:I <br /> LOCATION WTTITIN SITE(ooea,.l) X31 <br /> 1.TANK DESCRlPI70N (A scaled plot plan with the location of the UST system including huddingi and landmarks shall be Submitted the local agency.) <br /> TANK ID K 412 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK fj Yea Ll No 4u <br /> &,6 -7 X <br /> IP"Ya",aow+w.an.c,a4 ry aen m,epu®erl <br /> DATE INSTAL ED(YEAWMO) 43S TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 431 <br /> ADDITIONAL DESCRIPTION(Por iow re may) 431 <br /> IL TANK CONTENTS <br /> TANK USE 439 PETROLEUM TYPE JIM <br /> I, MOTOR VEHICLE FUEL ❑ REGULAR UNLEADED ❑2. LEADED Z)5. JET IVEL <br /> Uftwrked meplete Pe.d Typii) Ib. PREMIUM UNLEADED Q 3. DIESEL ❑6. AVIATION FUEL <br /> ❑2.NON-FUEL PETROLEUM ❑la MIDGRADE UNLEADED ❑4.GASOHOL ❑99.OTHER <br /> ❑3. CHEMICAL PROrYUCT COMMON NAME(Prom IIS a M1e Imarocy p.lte) f41 CAS#(horn ttuaww mmmals Ln-y pw) 442 <br /> Q ( udm tl DOUS WASTE 1 i ! goao <br /> (Ixladm lked Oil) // /(p/w/'(/ � (/ 7 <br /> ❑93.UNKNOWN LJ"� <br /> ITL TANK CONSTRUCTION <br /> TYPE OF TANK El 71. DOUBLE <br /> GLE WALL 3. SINGLE WALL WITH s, SrNGLE WALL WITH INTERNALBLADDER SYSTEM 443 <br /> (Ch"kaneimmo-y) EXTERIOR MEMBRANE LINER C)93.UNKNOWN <br /> WALL ❑4. SIGNLE WALL IN VAULT ❑99. OTHER <br /> TANK MA'I'EIIIAL-pdmay tr,k 0 1. BARE STEEL Gn. FIBERGLASS/PLASTIC u 5. CONCRETE U95. UNKNOWN 444 <br /> (Choek a rum 0*) ❑2 STAINLESS J'ITP,I, ❑4. STEEL CLAD W/nDERGLASS ❑8. PRP COMPTIBLE W/Io0%METHANOL ❑99.OTHER <br /> REINFUKCED PLASTIC(FRP) <br /> TANK MATERIAL-wn4Yyt-k El I. BARESTEEL 3. PIBEROLASS/PLASI'1C U 5. CONCRETE 95. UNKNOWN 445 <br /> (Check one itemwy) (12. STAINLESS STEEL [14. STEEL CLAD WIF10E9GLASS ❑8. PRP COMPTIBLE W/Iw%METHANOL ❑99.OTHER <br /> REINFORCHO PLASTIC(FRP) ❑10.COATED STEEL <br /> ❑S. CONCRETE <br /> TANK INTERIOR L1NTN0 1.RUBBER LINED 3.EPDXY LINING LASS LINING 95.uNl(NOWN 444 DATE INSTALLED 447 <br /> OR COATING ❑2 ALKYD LINING ❑A PHENOLIC LINING jefiI.NLINED ❑99 OTHER <br /> (Check ane item wy) (Pa loc.l urs only) <br /> OTHM COKKOSION ❑1 MANUPACTVRED CATHODIC ❑3 PIBL'RGLASS MNFORCW PLASTIC 95 UNKNOWN w DATE INSTALLED 449 <br /> PRUIEC110N IF APPLICABLE PROTECTION ❑4 INTPESSED CURRANT ❑99 OTHER <br /> (Cheek on omn-dy) L)2 SACRIFICIAL ANODE (P-1-9,eeaa)y) <br /> SPILL AND OVERFILL YEAR INSTALLED 450 TYPE(�„c._y) 451 71,11 <br /> ILL PROTECTION EOUIPMENT:YEAR INSTALLED 452 <br /> (Ct,.&.11"Woy) SPILL CONTAINMENT RM ❑3FILL TUBE SHUT OFF VALVE <br /> VROP TU13E 0 2 DALL FLOAT Q 4 EXEMPT <br /> 30STIUKER I'LATE <br /> IV.TANK LEAK DETECTION(A 4aa4t a„a(4re mamtona8 pwyn m x.11 be mbdaed a 0,.Ia.l raa ry,) <br /> IF SINGLE WALL TANK(0, %WI thmwey) 433 rP DOUBLE WALL TANK OR TANK WlT[I BLADDER 451 <br /> ( .imm ooy) <br /> ❑I VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MTa) ❑ SUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑2 AUTOMATIC TANK GAUGING(ATG) ❑6 VADOSE ZONE 2 LroNTINUOUS INTP.RSTrnAL MONITORING <br /> ❑3 CON'nNUOUS ATG ❑7 GROUNDWATER ❑3 MANUAL MONITORING <br /> ❑4 STATISTICAL:1NVFNTORY RECONCILIATION ❑8 TANK TFSTTNO <br /> (SIR) BIENNIAL TANK TESTING ❑99 OTHER <br /> IV.TANK CLOSURE rNFORMATION/PERMANENT CLOSURE.IN PLACE <br /> ESTIMA1W VATP.I,AST USED(YR/MOMAY) aS5 ESTIMATED QUANTITY OF SUBSTANCE REMArK FILLED WITH INF,RT MATERIAL? 4'7 <br /> gallons ❑Ves ❑ No <br /> UPCF(12/99 revised) 10 Formerly SWRCB Form B <br />