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rI UNIFIED PROGRAM CONSOLIDATED FORM ``\O`\�� TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 �, (two pages per tank) Page of _ TYPE OF ACTION ❑ 1 NEW SITE PERMIT 4 AMENDED PERMIT Z S CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE L. (Check one item only) ❑ 7 PERMANENTLY CLOSED ON SITE 3 RENEWAL PERMIT (Specify reason- for local use only) (Specify reason- for local use only) 8 TANK REMOVED 430 BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As)3 FACILITY ID: FA 01 73 Quick Stuff #7789 � LOCATION WITHIN SITE (Optional) 431 1. TANK DESCRIPTION (A scaled plot plan with the location of the US I system including buildings and landmarks shall e submitted to the local agency. TANK ID # es X No 434 Xerxes If "Yes", complete one page for each compartment. DATE INSTALLED (YEAR/MO) TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 7/2006 20,000 1 AUDIT IONAL DESCRIPTION (For local use only) 438 Il. TANK TANK USE 439 PLIROLLUM TYPE 440 1. MOTOR VEHICLE FUEL ❑x 1 a. REGULAR UNLEADED 2. LEADED S. JET FUEL (If marked complete Petroleum Type) ❑ lb. PREMIUMUNLEADED 3. DIESEL 6. AVIATION FUEL ❑ 2. NON -FUEL PETROLEUM ❑ ic. MIDGRADE UNLEADED 4. GASOHOL 99.OTHER 3. CHEMICAL PRODUCT COMMON NAME (from Hazardous Materials Inventory page) 441 CAS# (from Hazardous Materials Inventory page) 442 4. HAZARDOUS WASTE (Includes Used Oil) ❑ 95. UNKNOWN 111. TANK CONSTRUCTION I YPEOF I ANK L I . SINGLE WALL L 3. SINGLE WALL WITR 5. SINGLE WALL WITH INTERNAL 8LAUULH SYS I EM 443 (Check one item only) EXTERIOR MEMBRANE LINER ❑ 95. UNKNOWN X 2. DOUBLE WALL ❑ 4. SIGNLE WALL IN VAULT ❑ 99.OTHER TANK MATERIAL - primary tank L 1 . BARE STEEL L 3. FIBLFIC�LASb/ IC L 5. CONCRETE L 95. UNKNOWN 444 (Check one item only) 2. STAINLESS STEEL ❑ 4. STEEL CLAD W/FIBERGLASS R. FRP COMPTIBLE W/100% METHANOL 99.OTHER REINFORCED PLASTIC (FRP) TANK MATERIAL - secondarytank (Check one item only) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD W/FIBERGLASS Z 8. FRP COMPTIBLE W/100% METHANOL 99.OTHER REINFORCED PLASTIC (FRP) F-1 10. COATED STEEL ❑ 5. CONCRETE TANK INTERIOR LINING l.RUBBERLINLL) L 3. EPDXY LINING L 5.ULASbLINING L 95. UNKNOWN 446 DATE INSTALLED 44/ OR COATING ❑ 2 ALKYD LINING 4 PHENOLIC LINING 1 ❑K 6 UNLINED ❑ 990THER (Check one item only) (For local use only) OTHER CORROSION ❑ 1 MANUFACTURED CATHODIC 3 FIBERGLASS REINFORCED PLASTIC 95 UNKNOWN 448 DATEINSTALLED 449 PROTECTION IF APPLICABLE PROTECTION 4IMPRESSED CURRENT ❑ 99 OTHER (Check one item only) F] 2 SACRIFICIAL ANODE (For local use only) SPILL AND OVERFILL YEARINSTALLED 450 TYPE (local use only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Check all that apply) Z I SPILL CONTAINMENT 2006 1 ALARM 2006 ❑ 3 FILL TUBE SHUT OFF VALVE ❑x 2 DROP TUBE 2006 2 BALL FLOAT 2006 ❑ 4 EXEMPT ❑K 3 STRIKER PLATE 2006 IV. TANK LEAK DETECTION (A description of the monitoring program shall be submitted to the local agency.) IF SINGLE WALL TANK (Check all that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER (Check one 454 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 I 2 CONTINUOUS INTERSTITIAL MONITORING ❑ 3 CONTINUOUS ATG 7 GROUNDWATER 3 MANUAL MONITORING 4 STATISTICAL INVENTORY RECONCILIATION ❑ 8 TANK TESTING (SIR) BIENNIAL TANK TESTING 99 OTHER IV. TANK CLOSURE INFORMATION / PERMANENT CLMHL IN FLACI: ESTIMATED DATE LAST USED (YR/MO/DAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING TANK FILLED WITH INERT MATERIAL? gallons ❑ Yes [-] No UPCF 0 2/99 revised) 10 Formerly SWRCB Form B