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"A <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 1 TA7-71 <br /> NKS <br /> (two pages per tank) <br /> Page _ of <br /> TYPE OF ACTION1.NEW SITE PERMIT ❑ 4.AMENDED PERMIT 5. CHANGE OF INFORMATION) ❑ 6. TEMPORARY SITE CLOSURE <br /> (Check one item only) 0 <br /> ❑3.RENEWAL PERMIT ❑ 7. PERMANENTLY CLOSED ON SITE <br /> (Specify mason-for local use only) (Specify change.for local use only) <br /> ❑ 8. TANK REMOVED 430 <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) FACILITY 10#CS 1 <br /> Al <br /> e <br /> PIN <br /> LOCATION WITHIN SITE(Optionaq 43 <br /> I.TANK DESCRIPTION <br /> TANK ID# TANK MANUFACTURER <br /> COMPARTMENTALIZED TANK ❑ Yeso <br /> If'Yes',Complete one page for each com nt. <br /> DATE INSTALL (YEAR/MO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> ADDITIONAL DESCRIPTION(Forlocal use only) <br /> II.TANK CONTENTS <br /> TANK USE 432 PETROLEUM TYPE <br /> 1. MOTOR VEHICLE FUEL 13 la. REGULAR UNLEADED ❑ 2. LEADED C35. JET FUEL t <br /> (If arked,complete Petroleum Type) ❑1b. PREMIUM UNLEADED 3. DIESEL ❑ 6. AVIATION FUEL <br /> ❑ 2. NON-FUEL PETROLEUM 131c MIDGRADE UNLEADED ❑ 4. GASOHOL ❑99. OTHER <br /> ❑ 3. CHEMICAL PRODUCT <br /> COMMON NAME(hom Hazardous Materials Inventory page) CAS#(liom Hazardous Materials <br /> ❑ 4. HAZARDOUS WASTE(includes Inventory page) <br /> Used Oil) <br /> 1195- UNKNOWN <br /> Ill.TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1. SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> (Check one item only) 2. DOUBLE WALL EXTERIOR MEMBRANE LINER <br /> ❑95. UNKNOWN <br /> ❑ 4. SINGLE WALL IN A VAULT ❑99 OTHER <br /> TANK MATERIAL•primary tank ❑ 1 BARE STEEL K3. FIBERGLASS/PLASTIC ❑ 5. CONCRETE ❑95. UNKNOWN <br /> (Check one item only) ❑ 2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS8. FRP COMPATIBLE W/100%METHANOL C399. OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL.secondary tank ❑ 1 BARE STEEL 2. FIBERGLASS/PLASTIC ❑ 8. FRP 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) 1110, COATED STEEL <br /> ❑ S. CONCRETE <br /> TANK INTERIOR LINING ❑ 1, RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING ❑95. UNKNOWN433 DATE INSTALLED <br /> OR COATING <br /> (Check one item only) ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING X6. UNLINED ❑99. OTHER <br /> (For local use only) <br /> OTHER CORROSION <br /> PROTECTION IF APPLICABLE 111. MANUFACTURED CATHODIC 113. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN 434 DATE INSTALLED <br /> PROTECTION <br /> (Check one item on ) ❑ 4. IMPRESSED CURRENT 1199. OTHER <br /> �' ❑ 2. SACRIFICIAL A I (For local use only) <br /> SPILL AND OVERFILL YEAR INSTALLED TYPE(For local use only) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (Check all that apply) <br /> 111. SPILL CONTAINMENT ❑ 1.ALARM . FILL TUBE SHUT OFF VALVE <br /> ❑ 2. DROP TUBE f ❑ 2. BALL FLOAT ❑ 4. EXEMPT <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 item only): <br /> ❑ 1, VISUAL(EXPOSED PORTION ONLY) N ❑ 5. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ 6. 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 ❑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 1 TANK FILLED WITH INERT MATERIAL? <br /> gallons <br /> ❑Yes ❑No <br /> 66 <br /> ! ` a <br /> CUPAFORM(4/99) <br /> Formerly SWRCB Form B <br />