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UNIFIED PROGRAM CONSOLIDATED FORM D ECE PAG 1 �� ANKS `� VVVV UNDERGROUND STORAGE TANKS-TANK 4 Z001wopages per tank) ❑�fV� N{f�{�q��,ALS of _ ❑ 5.CHANGE OF INFORMATION) ❑ 7 [�CQtOSEDDNSITE TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 4.AMENDED PERMIT WE61#a (Check one item only) ❑3.RENEWAL PERMIT CS,.,,,reason-forlocal use only) (Specify change-for local use only) ❑ B.TANK REMOVED 430 1 FACILITY ID#. '"' BUSINESS NAME(Same as FA ILITY NAME or DBA-Doing Business As) ' THU 6 _ LOCATION WITHIN SITE(Optionao 431 I.TANK DESCRIPTION TANK MANUFACTURER - COMPARTMENTALIZED TANK ❑ Yes No .TANK ID# If'Yes',complete one page for each w artm nt 7� q 37 sr�� TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS DATE INSTAL D IYEARIMO) Oa O ADDITIONA DESCRIPTION(Forlocal use-11Y) 11.TANK CONTENTS TANK USE 432 PETROLEUM TYPE ❑ 5. JET FUEL ❑1a. REGULAR UNLEADED ❑ 2. LEADED ❑ 1. MOTOR VEHICLE FUEL 3. DIESEL ❑ 6.AVIATION FUEL (If marked,complete Petroleum Type) ❑1b. PREMIUM UNLEADED ❑ GASOHOL ❑99. OTHER ❑ 2. NON-FUELPETROLEUM ❑1c MIDGRADEUNLEADED CAS#(",#(from Hazardous Materials Inventorypage)- ❑ 3.CHEMICAL PRODUCT COMMON NAME(from Hazardous Materials Inventory page) ❑ 4. HAZARDOUS WASTE(Includes Used Oio - III.TANK CONSTRUCTION ❑ 3.SINGLE WALL WITH ❑ S. SINGLE WALL WITH INTERNAL BLADDER SYSTEM TYPE OF TANK ❑ 1. SINGLE WALL EXTERIOR MEMBRANE LINER ❑95. UNKNOWN (Check one item only) 2.DOUBLE WALL ❑ 4. SINGLE WALL IN A VAULT ❑99. OTHER / ❑95. UNKNO TANK MATERIAL-primary tank ❑ 1. BARE STEEL FIBERGLASS f PLASTIC ❑ 5. CONCRETE ��------,,y��y////9. OTHER (Check one item only) ❑ 2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑ B. FRP COMPATIBLE W/100%METHANOL �9 REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary tank El 1. BARE STEEL FIBERGLASS f PLASTIC ❑ 8. FRP COMPATIBLE W/100%METHANOLUNKNOWN id-9. OTHER (Check one item only) 2. STAINLESS STEEL ❑ 4.STEEL CLAD WIFIBERGLASS ❑ 9. FRP NON-CORRODIBLE JACKET ✓✓✓ REINFORCED PLASTIC(FRP) ❑10.COATED STEEL ❑ 5.CONCRETE DATE INS ALLED ❑ 3. EPDXY LINING � ❑ 5. GLASS LINING ❑95. UNKNO 33 � / TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑ 8. UNLINED KY-9.OTHER (For to 1 use only) OR COATING G ❑ 4. PHENOLIC LINING ❑ 2.AIKY D LININ DATE IN ALLED (Check one item on ) ❑95. UNKNO 34 4 OTHER CORROSION ❑ 1.MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC 9 OTHER (For to 1 use onty) PROTECTION IF APPLICABLEPROTECTION ❑ 4.IMPRESSED CURRENT (Check one item onty) ❑ 2.SACRIFICIAL ANODE. OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED YEAR INSTALLED TYPE(For local use only) SPILL AND OVERFILL ' ❑ 1.ALARM 3. FILL TUBE SHUT OFF VALVE • (Check all that appw ❑ 1. SPILL CONTAINMENT - ❑ 2. BALL FLOAT ❑ 4. EXEMPT ❑ 2. DROPTUBE ❑ 3 STRIKER PLATE ,> TANK I EAIC'DETECTiOFi,•' ^. .. IF DOUBLE WALL TANK OR TANK WITH BLADDER(Check one item only): IF SINGLE WALL TANK heck a0 that ap O 5. MANUAL TANK GAUGING(MTG) 1. VISUAL(SINGLE WALL IN VAULT ONLY)VADOSE ZONE 2. CONTINUOUS INTERSTITIAL MONITORING ❑ I�S1i/\ ❑ 1, VISUAL(EXPOSED PORTION ONLY) ❑ 6. ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ T GROUNDWATER ❑ 3. MANUAL MONITORING ❑ 3. CONTINUOUS ATG ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR)* ❑ B. TANK TESTING BIENNIAL TANK TESTING ❑99. OTHER CLOSURE INFORMATION)PERMANENT CLOSURE IN PLACE V.TAN-- ESTIMATED DATE LAST USED(YR/MOIDAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING K FILLED WITH INERT MATERIAL? 435 TAN ' gallons ❑Yes ❑No Formerly SWRCB Form CUPAFORM(4/99)