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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 1 6 f' (two pages per tank) Page 2of TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 4. AMENDED PERMIT ❑ 5. CHANGE OF INFORMATION) ❑ 6. TEMPORARY SITE CLOSURE (Check one item only) ❑ 7. PERMANENTLY CLOSED ON S1TE ❑3.RENEWAL PERMIT (Specify reason-for local use only) (Specify charge-for Neal use only) ❑ B. TANK REMOVED 430 BUSINESS NAME(Same as FAC LITY NA or DBA-Doing Business As FACILITY ID 0 1 &at,u -*- / I hr LOCATION WI WSITE(Op#onaq 431 0 1.TANK DESCRIPTION TANK ID# TANK MANUFACTURER COMPARTMENTALIZED TANK ❑ Yes NoTft - •,n I o r i (D .i ,. If'Yes',complete one page for each comlfaWm ht. DATE INSTALLED(YEAR/MO) TANK CAPACITY IN GALLONS V NUMBER OF COMPARTMENTS - l 1s DOCS ADDITIONAL DESCRIPTION(Forlocal use only) 11.TANK CONTENTS TANK USE 432 PETROLEUM TYPE 1. MOTOR VEHICLE FUEL (1a. REGULAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL (11 in. 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 COMMON NAME pCAS#(hom Hazardous Materials Inventory page) prom Hazardous Materials Inventory page) ❑ 4. HAZARDOUS WASTE(Includes Used 010 95. UNKNOWN 111.TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM (Check one dem only) )r2. DOUBLE WALL EXTERIOR MEMBRANE LINER ❑95. UNKNOWN ��11 ❑ 4. SINGLE WALL IN A VAULT ❑99 OTHER TANK MATERIAL-primary tank ❑ 1 BARE STEEL !. FIBERGLASS/PLASTIC ❑ 5. CONCRETE ❑95. UNKNOWN (Check one item only) ❑ 2. STAINLESS STEEL ❑4. STEEL CLAD WIFIBERGLASS *. FRP COMPATIBLE W/100%METHANOL ❑99. OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL.secondary tank ❑ 1 BARE STEEL FIBERGLASS/PLASTIC 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 C195. UNKNOWN433 DATE INSTALLED OR COATING ., Q/ ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING 6. UNLINED ❑99. OTHER (Check one item on ) (For local use only) OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC 3. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN 434 DATE INSTALLED PROTECTION IF APPLICABLE PROTECTION ❑ . IMPRESSED CURRENT ❑99. 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 all that apply) ❑ 1 SPILL CONTAINMENT y❑1 1. ALARM ❑ 3. FILL TUBE SHUT OFF VALVE C12. DROP TUBEKI[_ 2. BALL FLOAT J.q_U ❑ 4. EXEMPT ❑ 3. STRIKER PLATE qqT IV.TANK LEAK DETECTION IF SINGLE WALL TANK Check all that apply): 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)+ ❑ S. TANK TESTING BIENNIAL TANK TESTING ❑99, OTHER V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE E5TJM TEE'D�DATE LAST USED(YRIMOIDAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 1 TANK FILLED WITH INERT MATERIAL? ft gallons ❑Yes ❑No l g,�o CUPAFORM(4/99) ��0 Formerly SWRCB Form B