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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 item only ❑ 7. PERMANENTLY CLOSED ON SITE ❑3.RENEWAL PERMIT (Spm,mason-for local use only) (Specify change-for local use only) ❑ 8. TANK REMOVED 430 BTfl F USINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) FACILITY 10# 1 ll s / �! LOCATION WITHIN SITE(Optionaq 431 v. I l C 7-e) 6 IV 1.TANK DESCRIPTION TANK ID# 71 /TANK MANUFACTURE `. COMPARTMENTALIZED TANK �'Yes,.:., No i ,� If'Yes',complete one page for each co pa ent. DATE INSTALLED(YEAR/MO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS 12-15,- ® - 9 . ADDITIONAL DESCRIPTION(Forlocal use only) IL TANK CONTENTS TANK USE 432 PETROLEUM TYPE 1. MOTOR VEHICLE FUEL .a. REGULAR UNLEADED ❑ 2. LEADED ❑ 5.JET FUEL (It marked,complete Petroleum Type) ❑-fbPREMIUM UNLEADED ❑ 3. DIESEL ❑ 6. AVIATION FUEL ❑ 2. NON-FUEL PETROLEUM ❑tc MIDGRADE UNLEADED ❑ 4. GASOHOL ❑99. OTHER ❑ 3. CHEMICAL PRODUCT CAS#prom Hazardous Materials inventory page) COMMON NAME(from Hazardous Materials Inventory page) ❑ 4. HAZARDOUS WASTE(Includes Used Oil) 95, KNOWN 111.TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM (Check one item only) M-2-DOUBLE WALL EXTERIOR MEMBRANE LINER ❑95. UNKNOWN ❑ 4. SINGLE WALL IN A VAULT [199. OTHER TANK MATERIAL-primary tank ❑ 1 BARE STEEL ❑ 3. FIBERGLASS/PLASTIC ,❑., 5/CONCRETE ❑95. UNKNOWN (Check one item only) ❑ 2. STAINLESS STEEL ❑4. STEEL CLAD WIFIBERGLASS W,B. FRP COMPATIBLE W/100%METHANOL ❑99. OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary tank ❑ 1 BARE STEEL . FIBERGLASS/PLASTIC ❑ 8. FRP COMPATIBLE W/100%METHANOL ❑95. UNKNOWN (Check one item only) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD WIFIBERGLASS ❑ 9. FRP NON-CORRODIBLE JACKET ❑99. OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL ❑ 5. CONCRETE TANK INTERIOR LININGDATE INSTALLED OR COATING ❑ i. RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING ❑95. UNKNOWN433 ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING ❑ 6. UNLINED ❑99. OTHER (For local use only) (Check one item only) DATE INSTALLEO OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN 434 PROTECTION IF APPLICABLE PROTECTION ❑ 4. IMPRESSED CURRENT ❑99. OTHER (For local use only) (Check one item only) ❑ 2. SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED TYPE(For local use only) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED (Check all that apply) Erll SPILL CONTAINMENT 1. ALARM [3'3. FILL TUBE SHUT OFF VALVE C 2. DROP TUBE it ❑ 2. BALL FLOAT ❑ 4. EXEMPT C�3. STRIKER PLATE 1 IV.TANK LEAK DETECTION IF SINGLE WALL TAN KCheck 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) . T AUTOMATIC TANK GAUGING(ATG) ❑ 6. VADOSE ZONE CONTINUOUS INTERSTITIAL MONITORING ❑ ' ❑ 3. CONTINUOUS ATG - ❑ 7. GROUNDWATER ❑ 3. MANUAL MONITORING ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR) ❑8 TANK TESTING BIENNIAL TANK TESTING ❑99. OTHER V.TANK CLOSURE INFORMATION f PERMANENT CLOSURE IN PLACE ESTIMATED DAT,,_ ST USED(YR/MO/DAY) ESTIMATED QUANTITY OF SUSSTANgE REMAINING 435 1 TANK FILLED WITH INERT MATERIAL? gallons Yes ❑No CUPAFORM(4/99) Formerly SWRCB Form B