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4AOL r - UNIFIED PROGRAM CONSOLIDATED FORM 7��i W 9 V) TANKS UNDERGROUND STORAGE TANKS-TANK PAM12 4 2006 (two pages per tank) _of_ TYPE OF ACTION ❑1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT HANGE OF INFORMATION ❑ 6 TEM X $O° (Check one item only) ❑ 7 PERMANENTLY CLOSED ON ❑ 3 RENEWAL PERMIT (Specify reason-for local use only) (Specify reason-for local use only) ❑ 8 TANK REMOVED 430 BUSIN ME(Same FACILITY NAME or DBA-Doing Business As) I FACILITY ID: I ® 3 FTT L ATI N WITHIN SITE(Optional) 431 I.TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local agency.) TANK ID# 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK ❑Ye No 434 If"Yes",complete one page for each compartment. DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS 437 -1 ADDITIONAL DES IPI N(For local use only) 1 439 II.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 MOTOR VEHICLE FUEL ❑ REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (If marked complete Petroleum Type) lb. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION FUEL ❑2. NON-FUEL PETROLEUM ❑lc. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER ❑3. CHEMICAL PRODUCT COMMON NAME(from Hazardous Materials Inventory page) 441 CAS#(from Hazardaa Materials Inventory page) 442 ❑4. HAZARDOUS WASTE (Includes Used Oil) ❑95.UNKNOWN III. TANK CONSTRUCTION TYPE OF TANK 1. SINGLE WALL 3. SINGLE WALL WITH Ll 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one item only) EXTERIOR MEMBRANE LINER ❑95. UNKNOWN DOUBLE WALL ❑4. SIGNLE WALL IN VAULT ❑99. OTHER TANK MATERIAL-primary tank Ll 1. BARE STEEL3. FIBERGLASS/PLASTIC 0 5. CONCRETE 0 95.UNKNOWN 444 (Check one item ally) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑8.FRP COMPTIBLE W/100%METHANOL [199.OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary tank 1. BARE STEEL . FIBERGLASS/PLASTIC C3 5. CONCRETE U 95.UNKNOWN 445 (Check are item only) ❑2. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPTIBLE W11000%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10.COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING 0 1.RUBBER LINED 3.EPDXY LINING ❑5.GLASS LINING ❑95.UNKNOWN 446 DATE INSTALLED 447 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING UNLINED ❑99 OTHER (Check one item only) (For local use only) OTHER CORROSION ❑1 MANUFACTURED CATHODIC ❑3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN 449 DATE INSTALLED 449 PROTECTION IF APPLICABLE PROTECTION ❑4 IMPRESSED CURRENT ❑99 OTHER / (Check are item only) ❑2 SACRIFICIAL ANODE f (For local use only) SPILL AND OVERFILL YEAR INSTALLED 450 TYPE(local nye only) 451 OVERFILL PROTECTION EQUIPMENMYEAR INSTALLED 452 (Check all that apply) ❑I SPILL CONTAINMENT ALARM ❑3 FILL TUBE SHUT OFF VALVE 2 DROP TUBE ❑2 BALL FLOAT ❑4 EXEMPT 3 STRIKER PLATE IV.TANK LEAK DETECTION(A description of the monitoring program shall be submitted to the local agency.) IF SINGLE WALL TANK(Check all that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 (Check one item only) ❑1 VISUAL(EXPOSED PORTION ONLY) 11b 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 ❑8 TANK TESTING (SIR) BIENNIAL TANK TESTING ❑99 OTHER IV.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 47T7 FILLED WITH INERT MATERIAL? 457 gallons ❑Yes ❑ No UPCF(12/99 revised) 10 Formerly SWRCB Form B