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Mw 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 ❑ S. CHANGE OF INFORMATION) ❑ 6. TEMPORARY SITE CLOSURE (Check one Hem only) ❑ 7. PERMANENTLY CLOSED ON SITE ❑3.RENEWAL PERMIT (SpecNy reason-for local use only) (Specify change-for local use only) ❑ S. TANK REMOVED 430 V� BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 'FACILITY ID N 1 '1/05EM (7E LOCATION WITHIN SITE(Optional) 431 100 l C YC'Y��-1�1 a 1.TANK DESCRIPTION \r T 0 Q TANK MANUFACTURER ra COMPARTMENTALIZED TANK LY7 Yes ❑ No C)",/5�U I TO�` /�b) ('!�_t N �1'T� If"Yes",complete one page for each compartment. DA INSTALLED(YEEARIMOO))) TANK CAPACITY IN GA`LLIO�N�SV 1 T�1 4 v s NUMBER OF COMPARTMENTS l 8000 Z ADDITIONAL DESCRIPTION(Forlocal use 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) 1b. PREMIUM UNLEADED ❑ 3. DIESEL ❑ 6. AVIATION FUEL ❑ 2. NON-FUEL PETROLEUM ❑1c MIDGRADE UNLEADED ❑ 4. GASOHOL ❑99. OTHER ❑ 3. CHEMICAL PRODUCT 11 4. HAZARDOUS WASTE(Includes COMMON NAME(from Hazardous Materials Inventory pays) CAS#(hom Hazardous Materials Inventory page) Used Dig 0 95, UNKNOWN Ill.TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM (Check one Hem only) 2, DOUBLE WALL EXTERIOR MEMBRANE LINER 1195. UNKNOWN ❑ 4. SINGLE WALL IN A VAULT ❑gg OTHER TANK MATERIAL-primary tank ❑ 1. BARE STEEL 3. FIBERGLASS/PLASTIC ❑ 5. CONCRETE ❑95. UNKNOWN (Check one Hem only) ❑ 2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑ 8. FRP COMPATIBLE W/100%METHANOL ❑99. OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary tank ❑ 1 BARE STEEL 3. FIBERGLASS/PLASTIC ❑ 8. FRP COMPATIBLE W/100%METHANOL ❑95. UNKNOWN (Check one Hem 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 - DATE INSTALLED OR COATING ❑ 1, RUBBER LINED ❑ 3. EPDXY LINING �❑ 5. GLASS LINING ❑95. UNKNOWN433 ❑ 2.ALKYD LINING ❑ 4. PHENOLIC LINING 1Lr-J• 6. UNLINED ❑99. OTHER (Check one Hem only) (For local use only) OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN 434 DATE INSTALLED PROTECTION IF APPLICABLE PROTECTION ❑ 4. IMPRESSED CURRENT 1199. OTHER (Check one item only) ❑ 2. SACRIFICIAL ANODE (For local use only) SPILL AND OVERFILL YEAR INSTALLED TYPE(For local use only) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED (Check allihat apply) ❑ 1 SPILL CONTAINMENT ❑ 1. ALARM ❑ 3. FILL TUBE SHUT OFF VALVE ❑ 2. DROP TUBE ❑ 2. BALL FLOAT ❑ 4. EXEMPT ❑ 3. STRIKER PLATE y�y IF SINGLE WALL TANK(Check all that a IF DOUBLE WALL TANK OR TANK WITH BLADDER Check one item only): ❑ 1, VISUAL(EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING(MTG) ❑ 1. 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(SIR)+ ❑ 8. TANK TESTING BIENNIAL TANK TESTING ❑gg. OTHER V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 1 TANK FILLED WITH INERT MATERIAL? gallons - ❑Yes ❑No 31Zvi M 3-�-ob W CUPAFORM(4/99) Formerly SVVRCB Form B