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D PROGRAM CONSOLIDATED F �1flU y'3003 TANKS UNDERGROUND STORAGE TANKS - TANK WE i 5 Ip ([wo pages per tank) Page_of II TYPE OF ACTION ❑I NEW SITE PERMIT ® 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (C�one 9crn only) ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT (Spccily sawn-fm balux only) (Specify anon-kr local we only) ❑ 8 TANK REMOVED 430 FACILITY ID: I BUSINESS NAME(S.a FACILITY NAME or DBA-Doing Businca N) 5 _ _ _ Van De Pol Enternrises 431 LOCATION WITHIN SITE(Optional) Northwest side of site I.TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local agency.) TANK ID# 433 TANK MANUFACTURER 431 COMPARTMENTALIZED TANK ❑Yes ® No 454 UNKNOWN TA 0`1" UNKNOWN rz-vea ca�lem nae ws<rar each c,ngertmeac DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY INGALLONS 636 NUMBER OF COMPARTMENTS 437 1988 10 OCO 1 ADDITIONAL DESCRIPTION(For bal ecru;; ) 439 II.TANK CONTENTS TANK USE 639 PETROLEUM TYPE 440 09,L MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED [12. LEADED [15. JET FUEL (ifmartel conPlmc Peooleom Type) ❑lb. PREMIUM UNLEADED ❑3. DIESEL 06. AVIATION FUEL ❑2. NON-FUEL PETROLEUM ❑le. MIDGRADE UNLEADED ❑4. GASOHOL f&99.OTHER ❑3. CHEMICAL PRODUCT COMMON NAME (from linaetdow Matenale Inventory page) 061 CAS#(from Flaamdom M eriak Inventory page) 443 [14. a� 4. HAZARDOUS WASTE 1\gGarra, Fut) UNKNOWN (IncludesUacl Oil) [195.UNKNOWN III. TANK CONSTRUCTION TYPE OF TANK ❑1. SINGLE WALL 3. SINGLE WALL WITH 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Chat one iron only) EXTERIOR MEMBRANE LINER [195. UNKNOWN ®2. DOUBLE WALL [14. SIGNLE WALL IN VAULT ❑99. OTHER TANK MATERIAL-pinery tank ❑1. BARE STEEL 0 3. FIBERGLASS/PLASTIC ❑5. CONCRETE 0 95. UNKNOWN 444 (Gunk one Item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑S. FRP COMPTIBLE W/100%METHANOL ❑99.OTHER REINFORCED PLASTIC FRP TANK MATERIAL-seeodmyuh 1. BARE STEEL ®3. FIBERGLASS/PLASTIC 0 5. CONCRETE 095. UNKNOWN 445 (Check one item only) ❑2. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS ❑S. FRP COMPTIBLE W/100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) [110.COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING 0 1.RUBBER LINED ❑3.EPDXY LINING ❑5.GLASS LINING [195.UNKNOWN 446 DATE INSTALLED 447 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING ®6 UNLINED ❑99 OTHER (Oteck one irmr only) (For local we only) OTHER CORROSION ❑I MANUFACTURED CATHODIC ❑3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN 449 DATE INSTALLED 449 PROTECTION IF APPLICABLE PROTECTION ❑4IMPRESSED CURRENT - ❑99 OTHER (Gish one Item only) ❑2 SACRIFICIAL ANODE (For lord use only) SPILL AND OVERFILL YEARINSTALLED 450 ME(local one only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 453 (ChcrJt all nm apply) ®1 SPILL CONTAINMENT 2003 ®1 ALARM 2003 ❑3 FILL TUBE SHUT OFF VALVE ®2 DROP TUBE 2003 ®2 BALL FLOAT 2003 ❑4 EXEMPT ®3 STRIKER PLATE 1988 IV.TANK LEAK DETECTION(A description.Rine monitoring pmgamnhNl be auhmitted to the lonl agency) IF SINGLE WALL TANK(chnckdl wt epply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 (Chnck 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 ❑8 TANK TESTING (SIR) BIENNIAL TANK TESTING ❑99 OTHER IV.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 655 ESTIMATED QUANTITY OF SUBSTANCE.REMAINING 056 TANK FILLED WITH INERT MATERIAL? 457 gallons ❑Yes ❑ No UPCF(12/99 revised) 10 Formerly SWRCB Form B