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D PROGRAM CONSOLIDATED F 71 T17 T.T1 -07) V TA1Vx5 UNDERGROUND STORAGE TANKS - T A E 1 62 (, O (two pages per tank) Page tel, of_(1 TYPE OF ACTION ❑1 NEW SITE PERMIT ® 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Chak on<rtcmonly) ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWALPERMIT (Specifyr<non-Torkvlos<mlly) (specify.-Porkraluseonly) ❑ 8 TANKREMOVED 438 BUSINESS NAME(Samcm FACWTYNAMEor DBA-Doing Business As) FACILITYID: 1 Van De Pol Ent rises LOCATION WITHIN SITE(Oµiona0 431 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# 632 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK Yes ® No 434 UNKNOWN UNKNOWN If-Ya',const one Mer each convaenen4 DATE INSTALLED(YEAR/MO) 413 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 432 1988 10,000 1 ADDITIONAL DESCRIPTION(For local use only) 438 II.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 448 I!&I. MOTOR VEHICLE FUEL [Ila. REQULAR UNLEADED ❑2. LEADED ❑S. JET FUEL (I[mhW mngleoa Pctrokwn Type) [;LIb. PREMRJM UNLEADED ❑3. DIESEL ❑6. AVIATION FUEL ❑2. NON-FUEL PETROLEUM ❑In. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER ❑3. CHEMICAL PRODUCT COMMON NAME(6 Barardom Materials lncanmry page) 461 CAS#(6nm Barardous Mataak Inventory page) u2 ❑4. HAZARDOUS WASTE UNKNOWN (Inewee Ue Oil) ❑95.UNKNOWN TIL TANK CONSTRUCTION TYPE OF TANK 1. SINGLE WALL 3. SINGLE WALL WITH LJ S. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Clack one item only) EXTERIOR MEMBRANE LINER ❑95. UNKNOWN ®2. DOUBLE WALL [14. SIGNLE WALL IN VAULT ❑99. OTHER TANK MATERIAL-primary oaNs ❑1. BARE STEEL 03. FIBERGLASS/PLASTIC 0 5. CONCRETE [195. UNKNOWN 444 (Check one nem only) ❑2. STAINLESS STEEL 134. STEEL CLAD WIFIBERGLASS ❑8. FRP COMPTIBLE W/100%METHANOL ❑99.OTHER REINFORCED PLASTIC FRP TANK MATERIAL-saoosry tank 0 1. BARE STEEL ®3. FIBERGLASS/PLASTIC 05. CONCRETE E]95. UNKNOWN 445 (Check one nem only) ❑2. STAINLESS STEEL E14. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPTIBLE W/ioo%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10.COATED STEEL ❑S. CONCRETE TANK INTERIOR LINING ❑1.RUBBER LINED ❑3.EPDXY LINING 0 5.GLASS LINING 0 95.UNKNOWN 446 DATE INSTALLED 442 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING ®6 UNLINED ❑99 OTHER (Check oa Joann only) (Far local use only) OTHER CORROSION ❑1 MANUFACTURED CATHODIC ❑3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN 048 DATE INSTALLED 449 PROTECTION IF APPLICABLE PROTECTION ❑4IMPRESSED CURRENT ❑99 OTHER (Check oM item only) ❑2 SACRIFICIAL ANODE (For ked case only) SPILL AND OVERFILL YEARINSTALLED 4% TYPE(lowlus<wiy) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Check all mar 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 dnctiptlon ofine annihilating Progeonn shall be subrouted come local agency.) IF SINGLE WALL TANK(cneckall than apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 (Check on,a=only) ❑I 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) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 452 gallons ❑Yes ❑ No UPCF(12/99 revised) 10 Formerly SWRCB Form B