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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 1 (two pages per tank) Page-of_ TYPE OF ACTION ❑ 1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Check one item only) ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT (Specify reason-for local use only) (Specify reason-for local use only) ❑ 8 TANK REMOVED 430 BUSINESS NAME(Same asFACILITY NAME orDBA-Doing Business As) 3 FACILITY ID: Ll 1 = Cts t1 111 LOCATION WITHIN SITE(Optional) 431 L TANK DESCRIPTION (A scaled plot plan With the location of the UST system including buildings and landmarks shall be submitted t the local agency.) TANK ID# 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK Yes ❑ No 434 If"Yes",complete one page for each compartment- DATE mpartment- DATnnE,,NS,,TAL D(YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 A�(/U ADDITIONAL DESCRIPTION(For local use only) 438 H.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 1. MOTOR VEHICLE FUEL Q REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (If marked complete Petroleum Type) lb. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION FUEL ❑2. NON-FUEL PETROLEUM ❑Ic. MIDGRADE UNLEADED ❑4. GASOHOL Cl 99.OTHER ❑3. CHEMICAL PRODUCT COMMON NAME(from Hazardous Materials Inventory page) 441 CAS#(from Hazardous Materials Inventory page) 442 ❑4. HAZARDOUS WASTE (Includes Used Oil) -// / n [[�// ( / I ( \ S✓ao -(,e(- 0 `,C /-❑95.UNKNOWN J III. TANK CONSTRUCTION TYPE OF TANK ElGLE WALL 3. SINGLE WALL WITH 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one item only) iEXTERIOR MEMBRANE LINER 095. UNKNOWN 2. DOUBLE WALL [_14. SIGNLE WALL IN VAULT ❑99. OTHER TANK MATERIAL-primary tank 1. BARE STEEL 3. FIBERGLASS/PLASTIC 5. CONCRETE 0 95. UNKNOWN 444 (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPTIBLE W/100%METHANOL ❑99.OTHER INFORCED PLASTIC(FRP) TANK MATERIAL-secondary tank Ll 1. BARE STEEL M 3. FIBERGLASS/PLASTIC U 5. CONCRETE U 95. UNKNOWN 445 (Check one item only) ❑2. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPTIBLE W/100%METHANOL [199.OTHER REINFORCED PLASTIC(FRP) ❑10.COATED STEEL Cl 5. CONCRETE TANK INTERIOR LINING 0 1.RUBBER LINED 0 3.EPDXY LINING LASS LINING 095.UNKNOWN 446 DATE INSTALLED 447 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING r6UNLINED ❑99 OTHER (Check one item only) (For local use only) OTHER CORROSION ❑1 MANUFACTURED CATHODIC ❑3 FIBERGLASS REINFORCED PLASTIC 95 UNKNOWN 448 DATE INSTALLED 449 PROTECTION IF APPLICABLE PROTECTION ❑4 IMPRESSED CURRENT ❑99 OTHER (Check we item only) ❑2 SACRIFICIAL ANODE (For local use only) SPILL AND OVERFILL YEAR INSTALLED 450 TYPE(local use only) 451 71,xLARM ILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Check all that apply) SPILL CONTAINMENT ❑3 FILL TUBE SHUT OFF VALVE (� ROP TUBE O X2BALL FLOAT ❑4 EXEMPT 3 STRIKER PLATE IV.TANK LEAK DETECTION(A description of the monitoring program shall be submitted to the local agency.) IF SINGLE WALL TANK(Check all that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 (Chet ne item only) ❑1 VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MTG) ❑ VISUAL(SINGLE WALL IN VAULT ONLY) ❑2 AUTOMATIC TANK GAUGING(ATG) ❑6 VADOSE ZONE 2 CONTINUOUS INTERSTITIAL MONITORING ❑3 CONTINUOUS ATG ❑7 GROUNDWATER ❑3 MANUAL MONITORING ❑4 STATISTICAL INVENTORY RECONCILIATION Cl 8 TANK TESTING (SIR) BIENNIAL TANK TESTING ❑99 OTHER IV.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DA Y) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 gallons ❑Yes ❑ No UPCF(12/99 revised) 10 Formerly SWRCB Form B