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r <br /> Y <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 1 <br /> (two pages per tank) <br /> Page _ of _ <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 4. AMENDED PERMIT Jsl 5. CHANGE OF INFORMATION) 9 ❑ 6. TEMPORARY SITE CLOSURE <br /> (Check one item only) ❑ 7. PERMANENTLY CLOSED ON SITE T~ <br /> ❑3.RENEWAL PERMIT OforlfO l use nly) p <br /> (Specify reason-for focal us*only) (Specify change-kr local use only) ❑ g, TANK REMOVED 430 � <br /> BUSINESS NAME(Same as FACILITYE or DB -Doing Business As) FACILITY ID N 1 <br /> wA7re,�,�r�t� 4- ccs f <br /> LOCATION WITHIN SITE(Optionao 431 <br /> 1.TANK'DESCRIPTION <br /> TANK ID# TANK MANUFACTURER COMPARTMENTALIZED TANK ❑ Yes No <br /> k_FA�`"G'/_ If"Yes",complete one page for each com artment. <br /> DATE INSTALLED(YEAR/MO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> ADDITIONAL DESCRIPTION(For local use only) <br /> IL TANK CONTENTS <br /> TANK USE 432 PETROLEUM TYPE <br /> ❑ 1. MOTOR VEHICLE FUEL Ella. REGULAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL <br /> (If marked,complete Petroleum Type) ❑lb. PREMIUM UNLEADED ❑ 3. DIESEL ❑ 6. AVIATION��F,�UEyyL,,//�J <br /> ❑ 2. NON-FUEL PETROLEUM ❑1c MIDGRADE UNLEADED ❑ 4. GASOHOL . OTHER LI A f.�� <br /> ❑ 3. CHEMICAL PRODUCT <br /> ❑ 4. HAZARDOUS WASTE(Includes COMMON NAME(from Hazardous Materials Inventory page) CAS#(from Hazardous Materials Inventory page) <br /> Used Oil) <br /> 0 95. "KNOWN <br /> 111.TANK CONSTRUCTION <br /> TYPE OF TANK SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. 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 /> ❑99. OTHER <br /> TANK MATERIAL-primary tank ­prlBARE STEEL ❑ 3. FIBERGLASS/PLASTIC ❑ 5. CONCRETE ❑95. UNKNOWN <br /> (Check one item only) ❑ 2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑ 8. FRP COMPATIBLE W/100%METHANOL ❑99. OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-secondarytank W, BARE STEEL ❑ 3. FIBERGLASS/PLASTIC ❑ 8. FRP COMPATIBLE W/100%METHANOL95. UNKNOWN <br /> (Check one item only) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD W/FIBERGLASS ❑ 9. FRP NON-CORRODIBLE JACKET .L`199. OTHER <br /> REINFORCED PLASTIC(FRP) 1110. 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 8. UNLINED ❑99. OTHER <br /> (Check one item only) (For local use only) <br /> OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC El 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 /> (Check all that apply) ❑ 1 SPILL CONTAINMENT <br /> ❑ 1. ALARM ❑ 3. FILL TUBE SHUT OFF VALVE <br /> ❑ 2. DROP TUBE ❑ 2. BALL FLOAT ❑ 4. EXEMPT <br /> ❑ 3. STRIKER PLATE <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) 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. CONTINUOUSATG - ❑ 7. GROUNDWATER ❑ 3. MANUAL MONITORING <br /> ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR)+ ❑ 8. TANK TESTING <br /> BIENNIAL TANK TESTING <br /> - 1199. OTHER <br /> V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LASS 1 (YR/MO/DAY) ESTIMATED QUANTITY OFF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL? <br /> gallons ❑Yes No <br /> CUPAFORM(4/99) Formerly SWRCB Form B <br />