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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 1 (two pages per tank) Page-of_ TYPE OF ACTION ❑I NEW SITE PERMIT Cl 4 AMENDED PERMIT 1w 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Check one item only) ❑ 7 PERMANENTLY CLOSED ON SITE l 1 ❑ 3 RENEWAL PERMIT (Specify recon-for local use only) (Specify,reason-for local use only) ❑ 8 TANK REMOVED 430 FACILITY ID: l BUSINESS NAME(Same u FACILITY NAME or DBA-Doing Business As) 3 431 OCAT ON WITHIN SITE(Optional) I.TANK DE ` IO (A scaled plot plan Ori 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 ❑Yes No 434 , t If"Yes",complete one page for each compartment. C, DATE INSTALLED(YEAR/MO) 43 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 439 ADDITIONAL DESCRIPTION(For local use only) II.TANK CONTENTS 440 TANK USE 439 PETROLEUM TYPE 1. MOTOR VEHICLE FUEL la. REGULAR UNLEADED ❑2.LEADED ❑5. IBT FUEL (If marked complete Pctroleum Type) ❑lb. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION FUEL ❑2. NON-FUEL PETROLEUM ❑ic. MIDGRADE UNLEADED ❑4. GASOHOL ❑�•QrkIER 442 441 CAS#(from Hazardous Materials Inventory page) ❑3.CHEMICAL PRODUCT COMMON NAME(from Hazardous Materials Invertory page) ❑4. HAZARDOUS WASTE (includes Used Oil) ❑95.UNKNOWN III. TANK CONSTRUCTION TYPE OF TANK 1. SINGLE WALL 3.SINGLE WALL WITH Ll S.SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one item Only) EXTERIOR MEMBRANE LINER ❑95.UNKNOWN 2. DOUBLE WALL ❑4. SIGNLE WALL IN VAULT ❑99- OTS TANK MATERIAL-ptimary tank 1. BARE STEEP 3. FIBERGLASS/PLASTIC 5.CONCRETE 95.UNKNOWN444 (Check one item only) C]2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPTIBLE W/100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary tank 1. BARE STEEL 3. FIBF1tGLASS/PLASTIC 5. CONCRETE 95.UNKNOWN 445 (Check one item only) [12. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS [19. FRP COMPf IBLE W/100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10.COATED STEEL. ❑5.CONCRETE DATE INSTALLED 447 TANK INTERIOR LINING ❑i.RUBBER LINED ❑3.EPDXY LINING ❑5.GLASS LINING 95.UNKNOWN 446 LI OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING ❑6 UNLINED ❑ DTR (Fa local use Daly) (Check one item Orly) 449 DATE INSTALLED 449 ❑ FIBERGLASS PLASTIC Q UNKNOWN OTHER CORROSION ❑1MANUFAC MANUFACTURED CATHODIC 99 PROTECTION IF APPLICABLE PROTECTION [34 ED CURRENT (For local use 0610 (Check me item only) ❑2 SACRIFICIAL ANODE452 45o TYPE(local tau only) est OVERFILL PROTECTION EQU(pMENT:YEAR INSTALLED SPILL AND OVERFILL YEAR INSTALLED ❑3 FILL TUBE SHAT OFF VALVE (Check all that apply) 1 SPILL CONTAINMENT 'JAI ALARM❑2 BALL FLOAT ❑4 EXEMPT 2 DROP TUBE C� 3 STRIKER PLATE IV.TANK LEAK DETECTION(A description of monitoring program shall be s"b"'i"`d w the local agency.) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 IF SINGLE WALL TANK(Check all that aPPIY) (Check one item only) ❑1 VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MTG) ❑I VISUAL(SINGLE WALL IN VAULT ONLY) 2 CONTINUOUS INTERSTITIAL MONITORING ❑2 AUTOMATIC TANK GAUGING(ATG) ❑6 VADOSE ZONE 0 3 MANUAL MONITORING ❑3 CONTINUOUS ATG ❑7 GROUNDWATER ❑4 STATISTICAL INVENTORY RECONCILIATION ❑8 TANKTESTING (SIR) BIENNIAL TANK TESTING ❑ 99 OTHER IV.TANK CLOSURE INFORMATION/PERMANENT CLOSURE PLACE 7 457 ass ESTIMATED QUANTITY OF SUBSTANCE REMAINING TANK FILLED WITH INERT MATERIAL. ESTIMATED DATE LAST USED(YR/MO/DAY) gallons ❑Yes ❑ No UPCF(12/99 revised) 10 Formerly SWRCB Form B