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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 1 I (tw es tank) Page of TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 4. AMENDED PERMIT ❑ 5. CHANGE OF INFORMATION) ❑ 6. TEMPORARY SITE CLOSURE (Check one item only) ❑ 7. PERMANENTLY CLOSED ON SITE ❑3.RENEWAL PERMIT (Specify reason-for local use only) (Specify change-for local use only) ❑ 8. TANK REMOVED 430 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) FACILITY ID# z' 1 3 APPK01V '651\17MPR/S5 LOCATION WITHIN SITE(Opffonal) 431 .i 3g2LY3 S. GHR�SNAW RoA� T R , cA. `1537,6 1.TANK DESCRIPTION TANK ID# TANK MANUFACTURER COMPARTMENTALIZED TANK ❑ Yes �i No _-11, o j-p i sc D If'Yes',complete one page for each compartment. DATE INSTALLED(YEAR/MO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS v c�O c7 / Colo ADDITIONAL DESCRIPTION(Forlocal use only) II.TANK CONTENTS TANK USE 432 PETROLEUM TYPE �1. MOTOR VEHICLE FUEL X1a. REGULAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL (Ifmarked,complete Petroleum Type) ❑tb. PREMIUM UNLEADED ❑ 3. DIESEL ❑ 6. AVIATION FUEL ❑ 2. NON-FUEL PETROLEUM ❑tc MIDGRADE UNLEADED ❑ 4. GASOHOL ❑99. OTHER ❑ 3. CHEMICAL PRODUCT CAS#(from Hazardous Materials Inventory page) COMMON NAME(from Hazardous Materials Inventory page) ❑ 4. HAZARDOUS WASTE(Includes C1 95 Used Oil) III.TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM (Check one item only) 2. DOUBLE WALL EXTERIOR MEMBRANE LINER 1195. UNKNOWN X ❑ 4. SINGLE WALL IN A VAULT ❑99. OTHER TANK MATERIAL-primary tank ❑ 1 BARE STEEL ;RC3. FIBERGLASS/PLASTIC ❑ 5. CONCRETE ❑95. UNKNOWN (Check one item only) ❑ 2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑ 8. FRP COMPATIBLE W1100%METHANOL ❑99. OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary tank ❑ 1 BARE STEEL 3. FIBERGLASS I PLASTIC ❑ 8. FRP COMPATIBLE W/100%METHANOL ❑95. UNKNOWN (Check one item only) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD W/FIBERGLASS ❑ 9. FRP NON-CORRODIBLE JACKET ❑99. OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL ❑ 5. CONCRETE TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING ❑95. UNKNOWN433 DATE INSTALLED OR COATING ❑ 2.ALKYD LINING ❑ 4. PHENOLIC LINING A6. UNLINED ❑99. OTHER (For local use only) (Check one item only) OTHER CORROSION ❑ MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC C195. UNKNOWN 434 DATE INSTALLED PROTECTION IF APPLICABLE PROTECTION1. ❑ 4. IMPRESSED CURRENT �99. OTHER (Check one item only) ❑ 2. SACRIFICIAL ANODE (For local use only) SPILL AND OVERFILL YEAR INSTALLED TYPE(For local use only) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED (Check all that apply) 1. SPILL CONTAINMENTham{ ❑ 1. ALARM 3. FILL TUBE SHUT OFF VALVE 2. DROP TUBE ❑ 2. BALL FLOAT ❑ 4. EXEMPT 3. STRIKER PLATE , TANK LEAK DETECTION IF SINGLE WALL TANK(Check 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) ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ 6. VADOSE ZONE 2. CONTINUOUS INTERSTITIAL MONITORING ' ❑ 3. CONTINUOUS ATG - ❑ 7. GROUNDWATER ❑ 3. MANUAL MONITORING ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR)+ ❑ 8. TANK TESTING BIENNIAL TANK TESTING ❑99. OTHER �1 V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE �'t• ESTIMATED DATE LAST USED(YR/MO/DAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 1 TANK FILLED WITH INERT MATERIAL? gallons ❑Yes ❑No CUPAFORM(4/99) Formerly SWRCB Form B