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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 1 / <br /> (two pages per tank) <br /> Page _ of _ <br /> 01 <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 4. AMENDED PERMIT 10 S. CHANGE OF INFORMATION) ❑ 6. TEMPORARY SITE CLOSURE <br /> (Check one dem only) <br /> ❑3.RENEWAL PERMIT ❑ 7. PERMANENTLY CLOSED ON SITE <br /> (Specify reason-for local use only) (Specify charge-for local use only) ❑ 8. TANK REMOVED 430 <br /> BUSINESS N E(Same as FACILITY NAME or DBA-Doing Business As) FACILITY 10# 1 <br /> c r <br /> J 6, <br /> LOCATION WITHIN SITE(Op#onao <br /> A <br /> 1.TANK DESCRIPTION <br /> TANK ID# - 5 TANK MANUFACTURER COMPARTMENTALIZED TANK Yes ❑ No <br /> l 7 <br /> If"Yes',complete one page for each compartment. <br /> DATE INSTALLED(YEARIMO) TANK CAPACITY NUMBER OF COMPARTMENTS 0 <br /> ADDITIONAL DESCRIPTION(Forlocal use only) <br /> 11.TANK CONTENTS <br /> TANK USE 432 PETROLEUM TYPE <br /> MOTOR VEHICLE FUEL [31a. REGULAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL <br /> )"(Irked,complete Petroleum Type) ❑1b. PREMIUM UNLEADED Y3. DIESEL ❑ 6. AVIATION FUEL <br /> ❑ 2. NON-FUEL PETROLEUM ❑1c MIDGRADE UNLEADED ❑ 4. GASOHOL ❑99. OTHER <br /> ❑ 3.CHEMICAL PRODUCT <br /> ❑ 4. HAZARDOUS WASTE(Includes COMMON NAME(horn Hazardous Materials Inventory page) CAS#(from Hazardous Materials Inventory page) <br /> Used 000 <br /> 95. UNKNOWN <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1. SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ S. SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> (Check one item only) ❑ 2. DOUBLE WALL EXTERIOR MEMBRANE LINER ❑95. UNKNOWN <br /> ❑ 4. SINGLE WALL IN A VAULT ❑99. OTHER <br /> TANK MATERIAL-primary tank ❑ 1 BARE STEEL ❑ 3. FIBERGLASS I PLASTIC ❑ 5. CONCRETE 1195. UNKNOWN <br /> (Check one dem only) 2. STAINLESS STEEL 4. STEEL CLAD W/FIBERGLASS ❑ 8. FRP COMPATIBLE W/100%METHANOL ❑99. OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-secondary tank ❑ 1 BARE STEEL3. FIBERGLASS/PLASTIC ❑ 8. FRP COMPATIBLE W/100%METHANOL ❑95. UNKNOWN <br /> (Check one item only) ❑ 2. STAINLESS STEEL 4. STEEL CLAD W/FIBERGLASS ❑ 9. FRP NON-CORRODIBLE JACKET ❑99. OTHER <br /> ' REINFORCED PLASTIC(FRP) ❑10. COATED STEEL <br /> ❑ 5. CONCRETE <br /> TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING ❑95. UNKNOWN433 DATE INSTALLED <br /> OR COATING <br /> ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING X. <br /> UNLINED ❑99.OTHER <br /> (Check one dem only) (For local use only) <br /> OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN 434 DATE INSTALLED <br /> PROTECTION IF APPLICABLE PROTECTION <br /> ❑ 4. IMPRESSED CURRENT ❑99. OTHER <br /> (Check one item only) ❑ 2. SACRIFICIAL ANODE (For local use only) <br /> SPILL AND OVERFILL YEAR INSTALLED TYPE(For local use only) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (Check all that apply) ❑ 1 SPILL CONTAINMENT <br /> ❑ 1. ALARM ❑ 3. FILL TUBE SHUT OFF VALVE <br /> ❑ 2. DROP TUBE ❑ 2. BALL FLOAT ❑ 4. EXEMPT <br /> ❑ 3. STRIKER PLATE <br /> -777 <br /> 1Y€`TANK LEAK'DETECTION <br /> IF SINGLE WALL TANK(Check all that ap ): IF DOUBLE WALL TANK OR TANK WITH BLADDER Check one item only): <br /> ❑ 1, VISUAL(EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ 6. VADOSE ZONE 2. CONTINUOUS INTERSTITIAL MONITORING <br /> ❑ 3. CONTINUOUSATG ❑ 7. GROUNDWATER ❑ 3. MANUAL MONITORING <br /> ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR)+ ❑ 8. TANK TESTING <br /> BIENNIAL TANK TESTING 099, OTHER <br /> IV A V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YR/MO/DAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING435 TANK FILLED WITH INERT MATERIAL? <br /> 7 <br /> gallons - ❑Yes ❑No <br /> CUPAFORM(4/99) Formerly SWRCB Form B <br />