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UNIFIED PROGRAM CONSOLIDATED FORM f <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 <br /> (two pages per tank) 1 <br />'t <br /> Page _ of _ <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 4. AMENDED PERMIT ❑ 5. CHANGE OF INFORMATION) ❑ 6. TEMPORARY SITE CLOSURE <br /> a? (Check one item only) <br /> ❑ 7. PERMANENTLY CLOSED ON SITE <br /> ❑3.RENEWAL PERMIT <br /> (Specify mason-for local use only) (Specify change-or local use only) ❑ 8. TANK REMOVED 430 <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) FACILITY ID# t <br /> AQ4.,D 6oZ.� <br /> LOCATION WITHIN SITE(Optional) 431 � <br /> 1� I Lc yo �1►4�TG c� <br /> I.TANK DESCRIPTION <br /> TANK ID# TANK MANUFACTURER i <br /> COMPARTMENTALIZED TANK ❑ Yes No <br /> 50 If-Yes-,complete one page for each compartment <br /> DATE INSTALLED(YEAR/MO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> ADDITIONAL DESCRIPTION(Forlocal use only) <br /> I <br /> II.TANK CONTENTS <br /> TANK USE 432, PETROLEUM TYPE <br /> I. MOTOR VEHICLE FUEL ta. REGULAR UNLEADED ❑ 7 LEADED ❑ 5. JET FUEL <br /> (If manned.complete Petroleum Type) ❑1b. PREMIUM UNLEADED ❑ 3. DIESEL ❑ 6. AVIATION FUEL <br /> ❑ 2. NON-FUEL PETROLEUM ❑tc. MIDGRADE UNLEADED ❑ 4. GASOHOL ❑99. OTHER <br /> ❑ 3. CHEMICAL PRODUCT <br /> COMMON NAME(from Hazardous Materials Inventory page) CAS#(from Hazardous Materials Inventory page) <br /> C3 4. HAZARDOUS WASTE(Includes <br /> Used Oil) <br /> g5. UNKNOWN <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1, SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ S. SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> (Check one item only) 2. DOUBLE WALL EXTERIOR MEMBRANE LINER ❑95. UNKNOWN <br /> ❑ 4. SINGLE WALL IN A VAULT <br /> 1199. OTHER <br /> TANK MATERIAL-pnmary tank ❑ I BARE STEEL 3. FIBERGLASS/PLASTIC ❑ 5. CONCRETE ❑95. UNKNOWN <br /> (Check one item only) ❑ 2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑ S. FRP COMPATIBLE W/100%METHANOL ❑99. OTHER <br /> REINFORCED PLASTIC IFRP) <br /> TANK MATERIAL-secondary tank ❑ I BARE STEEL 3. FIBERGLASS/PLASTIC ❑ a. :RP COMPATIBLE W/100%METHANOL ❑95. UNKNOWN <br /> (Check one item only) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD W/FIBERGLASS ❑ 9. FRP NON-CORRODIBLE JACKET ❑99. OTHER <br /> REINFORCED PLASTIC(FRP) ❑10. COATED STEEL <br /> ❑ 5. CONCRETE <br /> TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING ❑95. UNKNOWN433 DATE INSTALLED <br /> OR COATING <br /> ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING ❑ 5. UNLINED ❑99. OTHER <br /> (Check one item only) (For local use only) <br /> OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC 3. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN 434 DATE INSTALLED <br /> PROTECTION IF APPLICABLE <br /> PROTECTION ❑ 4. IMPRESSED CURRENT ❑99. OTHER <br /> (Check one item only) ❑ 2. SACRIFICIAL ANODE (For local use only) <br /> SPILL AND OVERFILL YEAR INSTALLED TYPE(For local use only) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> I <br /> (Cheek all that apply) 1 SPILL CONTAINMENT�� ❑ 1. ALARM ❑ 3. FILL TUBE SHUT OFF VALVE <br /> 2. DROP TUBE ❑ 2. BALL FLOAT ❑ 4. EXEMPT j <br /> 3. STRIKER PLATE <br /> IV. TANK LEAK DETECTION <br /> IF SINGLE WALL TANK(Check all that apply). IF DOUBLE WALL TANK OR TANK WITH BLADDER(Check one Rem only): <br /> ❑ 1. VISUAL(EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ 8. VADOSE ZONE 2. CONTINUOUS INTERSTITIAL MONITORING <br /> ❑ 3. CONTINUOUS ATG ❑ 7. GROUNDWATER ❑ 3. MANUAL MONITORING <br /> ❑ 4 STATISTICAL INVENTORY RECONCILIATION(SIR)• ❑ 8. TANK TESTING <br /> BIENNIAL TANK TESTING <br /> ❑99. OTHER <br /> V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YR/MO/DAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL? <br /> gallons <br /> 0 <br /> 1Y�e�s J ❑No <br /> CUPAFORM(4/99) Formerly SWRCB Form B <br />