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JNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 1 _ (two pages per tank) TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 4. AMENDED PERMIT ❑ 5. CHANGE OF INFORMATION) Cl S. TEMPORARY SITE CLOSURE (Check one item only) ❑ 7. PERMANENTLY CLOSED ON SITE ❑3.RENEWAL PERMIT (Specify mason-for local use only) iSpecily change-for local use only) ❑ 3. TANK REMOVED 430 BUSINESS NAME tSame as FACILITY NAME or DBA-Doing Business As) FACILITY 10# 7 A RZ 64)z-o 6 l LOCATION WITHIN SITE(Optional) 431 1-7-11 C O EYV`i Fes' M►91�T�C 1.TANK DESCRIPTION TANKIO# U_U1 TANK MANUFACTURER COMPARTMENTALIZED TANK ❑ yes -s No 5C '4 -'S "e )( C if'Yes',complete one Page for each compartment. DATE INSTALLED(YEARAMO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS 4 9 FADDITIONAL OESCRI TION(For local ase only) 11.TANK CONTENTS TANK USE 432 PETROLEUM TYPE 1. MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL (If marked.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 COMMON NAME(from Hazardous Materials Inventory page) CAS 0(from Hazardous Materials Inventory page) C1 a. HAZARDOUS WASTE(Includes Used Oil) Cl 95 UNKNOWN 111.TANK CONSTRUCTION TYPE OF TANK \❑ 1. SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM (Check one item only) 2, DOUBLE WALL EXTERIOR MEMBRANE LINER ❑95. UNKNOWN ❑ 4. SINGLE WALL IN A VAULT ❑99. OTHER TANK MATERIAL-primary tank ❑ 1 BARE STEEL FIBERGLASS I PLASTIC ❑ 5. CONCRETE ❑95. UNKNOWN (Check one item only) ❑ 2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑ S. FRP COMPATIBLE W/100%METHANOL ❑99. OTHER REINFORCED PLASTIC fFRP) TANK MATERIAL-secondary tank ❑ 1. BARE STEEL 3. FIBERGLASS,PLASTIC ❑ 8. FRP COMPATIBLE WI100%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 ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING ❑95. UNKNOWN433 DATE INSTALLED OR COATING El 2. ALKYD LINING ❑ 4. PHENOLIC LINING C16. UNLINED 1199. OTHER (Check one item only) (For ocal use only) OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC 3. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN 434 DATE INSTALLED PROTECTION IF APPLICABLE PROTECTION ❑ 4. IMPRESSED CURRENT ❑99. OTHER (Check one item only) C12. SACRIFICIAL ANODE (For local use only) SPILL AND OVERFILL YEAR INSTALLED TYPF_(For local use only) OVERFILL PROTECTION EQUIPMENT YEAR INSTALLED (Check all that apply) 1 SPILL CONTAINMENT _ ❑ 1. ALARM Is 3. FILL TUBE SHUT OFF VALVE 2. DROP TUBE _ ❑ 2. BALL FLOAT ❑ 4. EXEMPT 3. STRIKER PLATE IV. TANK LEAK DETECTION IF SINGLE WALL TANK(Check all that apply) 1 IF DOUBLE WALL TANK OR TANK WITH BLADDER(Check one item onW: ❑ 1. VISUAL(EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALLIN 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(SIR)+ ❑ 8. TANK TESTING BIENNIAL TANK TESTING ❑99, OTHER V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAV) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL? gallons ❑Yes ❑No CUPAFORM(4199) Formerly SWRCB Form B