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NIFIED PROGRAM CONSOLIDATED FORM TA UNDERGROUND STORAGE TANKS -TANK PAGE 1 gJL (I (IWO Pages pert k) Page TYPE OF ACTION ❑ 1. NEW SITE PERMIT ❑ 4. AMENDED PERMIT ❑ 5. CHANGE OF INFORMATION) ❑ B. TEMPORARY SITE CLOSURE (Check acre item Dory) ❑ 3. RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE (SpM/ymeaon-Iorloaluaa oMY) (Spry erchange-brla<al use only) & ❑ 0. TANK REMOVFrI e]O >?l BUSINESS NAMEgeDBA BwiAs)_ FACILITY ID;I 1 CC ��I�rjj�-j/o LOCATION MIN $ITE(Op#onM) 431 /j E• & 5 3 c/ r I. TANK DESCRIPTION TANK 10# #11 TANK MANUFACTURER _ KI COMPARTMENTALIZED TANK ❑Vas a (+ (/7_-✓P(rhC� 'Y.-', complete one page for earn wm Mnent. DATE INSTALLED(YEARMO) TANK PACITYINGALLONS� NUMBER OF COMPARTMENTS 14000 ADDITIONAL DESCRIPTION (Forlocal use only) II. TANK CONTENTS TANK USE 432 PETROLEUM TYPEae/ 1. MOTOR VEHICLE FUEL 11 l.. REGULAR UNLEADED L{VI. LEADED ❑ S. JET FUEL (Il maMeq campkb PelMeum Type) ❑ lb. PREMIUM UNLEADED ❑ 3. DIESEL ❑ S. AVIATION FUEL ❑ Z. NON -FUEL PETROLEUM ❑ 1c MIDGRADE UNLEADED ❑ 4. GASOHOL 1199. OTHER ❑ 3. CHEMICAL PRODUCT COMMON NAME(bomiforalHGYs Materials lnwntorypage) CAS#prom HOm8 0aa Materials/nwntorypage) ❑ 4. HAZARDOUS WASTE(IntluWs Used Dip 1195 UNKNOWN III. TANK CONSTRUCTION TYPE OF TANK 1, SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ S. SINGLE WALL NTH INTERNAL BUDDER SYSTEM (LM1eck Dna item Dory) ❑ 2. DOUBLE WALL EXTERIOR MEMBRANE LINER 1195. UNKNOWN ❑ 4. SINGLE WALL IN A VAULT ❑ 99. OTHER TANK MATERIAL -pnmary lank X SAFE STEEL ❑ 3. FIBERGLASS I PLASTIC ❑ 5. CONCRETE 13 95. UNKNOWN (Check orro them only) ❑ 2, STAINLESS STEEL ❑ 4. STEEL CLAD WIFIBERGLASS ❑ B. FRP COMPATIBLE Wil 00%METHANOL 11 N. OTHER REINFORCED PLASTIC (FRP) TANK MATERIAL-sxond.q sunk 11 1 BARE STEEL ❑ 3. FIBERGLASS/PLASTIC ❑ e. FRP COMPATIBLE W/100%METHANOL 1195. UNKNOWN (Check Dna item ony) 132. STAINLESS STEEL 114. STEEL CLAD WIFIBERGLASS 119. FRP NON -CORRODIBLE JACKET 1199.-L99. OTHER /V OX -R-, REINFORCED PLASTIC (FRP) 1110. COATED STEEL ❑ 5. CONCRETE TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING ❑ 95. UNKNONM433 DATE INSTALLED OR COATING Z. ALKYD LINING 114. PHENOLIC LINING. UNLINED ❑99. OTHER Checkoru item an) (Forbcel uae on OTHER ON ❑ 1, MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN 434 DATEINSTALLED PROTECTION IF PROTECTION IFAPPLICABLE PROTECTION ❑ 0. IMPRESSED CURRENTS. OTHER (Check one item only) ❑ 2. SACRIFICIAL ANODE (r-orlouluae only) SPILL AND OVERFILL YEAR INSTALLED TYPE (Forbca/use only) OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED q( ,I (Check a# that appy) ❑ 1. SPILL CONTAINMENT rs �,n,.)j p -y�-L�ke /✓� ❑ 1. ALARM 0 3. FILL TUBE SHUT OFF VALVE ❑ Z. DROP TUBE to ❑ 2. SALL FLOAT_ ❑ 4. EXEMPT ❑ 3. STRIKER PLATE T k ' N. TANK LEAK DETECTION IF SINGLE WALL TANK fChaolr all that apply) IF DOUBLE WALL TANK OR TANK WITH BLADDER (Check one dem ar ❑ 1, VISUAL(E)(POSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL (SINGLE WALLIN VAULT ONLY) ❑ 2. AUTOMATIC TANK GAUGING (ATG) ❑ B. VADOSE ZONE ❑ 2. CONTINUOUS INTERSTITIAL MONITORING ❑ 3. CONTINUOUSATG ❑ T. GROUNDWATER ❑ 3. MANUAL MONITORING 7 ❑ 4. STATISTICAL INVENTORY RECONCILIATION (SIR) ❑ B. TANK TESTING BIENNIAL TANK TESTING Ll 99. OTHER V. TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MOIDAAAYYS) -- i ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL? D / l gallons ❑ Yea No CUPAFORM (4/99) 6 lo�2y'D 1 0 Formerly SWRCB Forrn 8