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a <br />r 1 <br />Iaw <br />U IFIED PROGRAM CONSOLIDATED FORM <br />TANKS <br />UNDERGROUND STORAGE TANKS - TANK PAGE 1 <br />(two pages per tank) <br />Page _ of _ _l <br />/ <br />TYPE OF ACTION F-]1 NEW SITE PERMIT 4 AMENDED PERMIT Z5 CHANGE OF INFORMATION 6 TEMPORARY SITE CLOSURE <br />(Check one item only) 7 PERMANENTLY CLOSED ON SITE <br />❑ 3 RENEWAL PERMIT (Specify reason- for local use only) (specify reason- for local use only) 8 TANK REMOVED 430 <br />BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As)3 <br />FACILITY ID: <br />Quick Stuff #7789 <br />1 <br />FA <br />01 <br />73 <br />LOCATION WITHIN SITE (Optional) 431 <br />1. TANK DESCRIPTION (A scaled plot plan with the ocatlon o the UST system including ui Ings ana!andma_rFs­sF5`rF5e submitted to the local agency. <br />TANK ID # 432 <br />URER 433 <br />COMPARTMENTALIZED TANK Z YesEl No 434 <br />i <br />2A '/A /S 7< 7 <br />Xerxes <br />If "Yes", complete one page for each compartment. <br />DA INSTALL YEAR/M <br />TANK CAPACITY I G <br />A S 437 <br />7/2006 <br />12,000 <br />2 <br />(For local use only) 438 <br />II. TANK CONTENTS <br />TANK USE 439 <br />PETROLEUM TYPE 440 <br />1. MOTOR VEHICLE FUEL <br />F-1 la. REGULAR UNLEADED 2. LEADED S. JET FUEL <br />(If marked complete Petroleum Type) <br />F,� lb. PREMIUMUNLEADED 7 3. DIESEL F-1 6, AVIATION FUEL <br />2. NON -FUEL PETROLEUM <br />11 1c. MIDGRADE UNLEADED 0 4. GASOHOL F-] 99. OTHER <br />3. CHEMICAL PRODUCT <br />COMMON NAME (from Hazardous Materials Inventory page) 441 <br />CAS# (from Hazardous Materials Inventory page ) <br />F] 4. HAZARDOUS WASTE <br />(Includes Used Oil) <br />95. UNKNOWN <br />111. TANK CONSTRUCTION <br />I YPLOF I ANK Li I . SINGLE WALL 3. SINGLE WALL WITH 5. SINULIE WALL UER �,Y� I EM 443 <br />(Check one item only) EXTERIOR MEMBRANE LINER F� 95. UNKNOWN <br />2. DOUBLE WALL 4. SIGNLE WALL IN VAULT 99. OTHER <br />TANK MATERIAL -primary tank L 1 . BARE STEEL 3. FIBERGLASS / I - _1 IC .5, LUW_HF It L 95. UNKNOWN IIA4 <br />(Check one item only) F-1 2. STAINLESS STEEL 4, STEEL CLADW/FIBERGLASS 8. FRPCOMPTIFILE W/100% METHANOL❑ 99. OTHER <br />REINFORCED PLASTIC (FRP) <br />TANK MATERIAL - secondary tank L-1 1. BARES I ELL L 3. HBFR(,LASS/PLASIIL LJ S. LUNLREIL L] 95. UNKNOWN 445 <br />(Check one item only) 2. STAINLESS STEEL [-] 4. STEEL CLAD W/FIBERGLASS 8. FRP COMPTIBLE W/100% METHANOL 99. OTHER <br />REINFORCED PLASTIC (FRP) 10. COATED STEEL <br />S. CONCRETE <br />TANK INTERIOR LINING 1. RUBBER LINED Lj 3.EPDXYLINING L 5.GLASSLINING L95. UNKNOWN 446 DATE INSTALLED <br />OR COATING 2 ALKYD LINING 4 PHENOLIC LINING 1 7 6 UNLINED 99 OTHER <br />(Check one item only) (For local use only) <br />OTHER CORROSION 1 MANUFACTURED CATHODIC 3 FIBERGLASS REINFORCED PLASTIC 95 UNKNOWN 448 DATE INSTALLED 449 <br />PROTECTION IF APPLICABLE PROTECTION 4IMPRESSED CURRENT 99 OTHER <br />(Check one item only) r-1 2 SACRIFICIAL ANODE (For local use only) <br />SPILL AND OVERFILL YEARINSTALLED 450 TYPE (local use only) 451 <br />4 52 <br />(Check all that apply) 1 SPILL CONTAINMENT 2006 <br />1 ALARM 2006 F_� 3 FILL TUBE SHUT OFF VALVE <br />2 DROP TUBE 2006 <br />2 BALL FLOAT 2006 ❑ 4 EXEMPT <br />Q 3 STRIKER PLATE 2006 <br />(A description of the monitoring program shall be submitted to the local agency.) <br />IF SINGLE WALL TAN K (Check all that apply) 453 <br />IF DOUBLE WALL TANK OR TANK WITH BLADDER (Check one 454 <br />item only) <br />1 VISUAL (EXPOSED PORTION ONLY) 5 MANUAL TANK GAUGING (MTG) <br />E] 1 VISUAL (SINGLE WALL IN VAULT ONLY) <br />2 AUTOMATIC TANK GAUGING (ATG) 6 VADOSE ZONE <br />2] 2 CONTINUOUS INTERSTITIAL MONITORING <br />3 CONTINUOUS ATG 7 GROUNDWATER <br />F] 3 MANUAL MONITORING <br />4 STATISTICAL INVENTORY RECONCILIATION 8 TANK TESTING <br />(SIR) BIENNIAL TANK TESTING 99 OTHER <br />IV. TANK CLOSURE INFORMATION / PERMANENT CLO�URE IN PLACE <br />ESTIMATED DATE LAST USED (YR/MO/DAY) <br />ESTIMATED QUANTITY OF SUBSTANCE REMAINING <br />TANK FILLED WITH INERT MATERIAL? 457 <br />gallons <br />1:1 Yes I--] No <br />UPCF 02/99 revised) 10 Formerly SWRCB Form B <br />