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UNIFIED PROGRAM CONSOLIDATED FORM 7agANKSF_ UNDERGROUND STORAGE TANKS-TANK PAGE 1es per tank) Page _ of _ [3 5. CHANGE OF INFORMATION) El 6.TEMPORARY SITE CLOSURE TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 4.AMENDED PERMIT [) 7, PERMANENTLY CLOSED ON SITE (Check one Rem only) change-)orlocal use oMy) (38.TANK REMOVED 430 - ❑3.RENEWAL PERMIT (SPAY reason-lorfocai usa Doty) (SP fi 1 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) FACILITY IDN IV LOCATION THIN SITE(Optionaq 431 1.TANK'DESdR1PTIONYes ❑ No TANK MANUFACTURER COMPARTMENTALIZED TANK .TANK ID# ^ It'Yes',complete one page ore ch compartment 71s", 1s 7 f� 7 72 k NUMBER OFCOM DATE INSTALL (YEAR/MO) _ TANK CAPACITY IN GALLONS IOd l ADDITIONAL ESCRIPTION(For local use only) _ IL TANK CONTENTS TANK USE 432 PETROLEUM TYPE ❑ 5.JET FUEL 2 LEADED xv, Om.. REGULAR UNLEADED 6.AVIATION FUEL MOTOR VEHICLE FUEL 3. DIESEL m rked,complete petroleum Type) X1b. PREMIUM UNLEADED ❑99. OTHER [12. NON-FUEL PETROLEUM 3 1c. MIDGRADE UNLEADED ❑ 4.GASOHOL CAS#(from Hazardous Materials Inventory page) ❑ 3.CHEMICAL PRODUCT COMMON NAME(hom Hazardous Materials Inventory page) ❑ 4. HAZARDOUS WASTE(Includes Used Oil) 111-TANK CONSTRUCTION ❑ 3.SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM TYPE OF TANK p❑ 1. SINGLE WALL EXTERIOR MEMBRANE LINER ❑95. UNKNOWN (Check one Rem only) DOUBLE WALL ❑ 4. SINGLE WALL IN A VAULT ❑99.OTHER ✓ � ❑95. UNKNO ATERIAL-primary tank -❑ 1. BARE STEEL V-3. FIBERGLASS/PLASTIC ❑ 5.CONCRETE 99. OTHER TANK M (Check one Ram only) ❑ 2. STAINLESS STEEL ❑4. STEEL CLAD WIFIBERGLASS [IS. FRP COMPATIBLE WI100%METHANOL REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary tank ❑ 1 BARE STEEL 95. UNKNOWN,-7 FIBERGLASS/PLASTIC ❑ 8. FRP COMPATIBLE W/100%METHANOL ❑.,/J9.OT ER (Check one item only) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD WIFIBERGLASS ❑9. FRP NON-CORRODIBLE JACKET l,/OO� REINFORCED PLASTIC(FRP) ❑10.COATED STEEL ❑ S.CONCRETE DA�T�E IJNITTAALLLLEEDD- ❑ 3.EPDXY LINING ❑ 5. GLASS LINING ❑95. UNKNO�� 6 TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑ 6. UNLINED 9.-.OTHER (FOrio al use only) OR COATING [3 y ALKYD LINING ❑ 4.PHENOLIC LINING DATE IN TALLED (Check one Rem only) x ]OWN 434 6 OTHER CORROSION ❑ 1.MANUFACTURED CATHODIC ❑ 3.FIBERGLASS REINFORCED PLASTIC a 89.OTHER,�r„�+-`.Y W (Forlo at use only) PROTECTION IF APPLICABLE PROTECTION ❑ 4.IMPRESSED CURRENT �,y (Check one item only) ❑ 2.SACRIFICIAL ANODE EAR INSTALLED TYPE(For local use only) OVERFILL PROTECTION EQUIPMENT;YEAR INSTALLED SPILL AND OVERFILL - ❑ 1.ALARM . FILL TUBE SHUT OFF VALVE (Check BY that apply) ❑ 1, SPILL CONTAINMENT © - / U T if7-_ ❑ 2. BALL FLOAT ❑ 4.EXEMPT ❑ 2. DROP TUBE ❑ 3 STRIKER ti kC[ ICLEAKDETECTION ' IF DOUBLE WALL TANK OR TANK WITH BLADDER(Check one itemoniy). IF SINGLE WALL TANK Check all that apph9: [1 5. MANUAL TANK GAUGING(MTG) F.+,1. VISUAL(SINGLE WALL IN VAULT ONLY) ' ❑-1, VISUAL(EXPOSED PORTION ONLY) ❑ 6. VADOSE ZONE 2. CONTINUOUS INTERSTITIAL MONITORING ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ 7 GROUNDWATER ❑ 3. MANUAL MONITORING ❑ 3. CONTINUOUS ATG ❑ 9, TANK TESTING ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR)* ❑99. OTHER - BIENNIAL TANK TESTING - V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN 4 SLAC TANK FILLED WITH INERT MATERIAL? ESTIMATED DATE LAST USED(YR/MO/DAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING gallons ❑Yes ❑No Formerly SWRCB Form CUPAFORM(4/99)