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- METED PROGRAM CONSOLIDATED FO i � <br /> l VZP bfl- O\�\1 "1 a,AtltS <br /> UNDERGROUND STORAGE TANKS - T AGE 1 1 <br /> (1"'o Pagm PR tank) <br /> �.y P.r <br /> TYPE OF ACTION C31 NEW SITE PERMIT E3 AMENDED PERAQT 9(' S CHANGE OF IN�FOO7RMATION [36 TEMPORARY SITE CLOSURE <br /> «h) 4 Jin d li.�. ❑ 7 PERMANENTLY CLOSED ON SITE <br /> ❑ J RENEWAL PERMIT (3P.ifyms-b balm whl (SPmty lww.-b bd mwlyl I TANK REMOVED 410 <br /> BUSINESS NAME(sm4n FACam NAI. .oaA-Debre Au FACILITY ID: ' I <br /> pRLO 424, 0 tm- <br /> LOCATION WITHIN SITE(OP�.o 451 <br /> L TANK DFS ON (A sled plot plan with the loeuian of the system incllidiog buildings and Isndmarks dull be submitted to the local agency.) <br /> TANK M 0 X13 TANK MANUFACTURER a3 COMPARTMENTALIZED TANK Yes a 434 <br /> (p 0 Ngerw vti«^.waww.vs.rrwaw.P.e.�m. <br /> ;-d-DATE INST (YEAR/MO) 3 TANK CAPACITYGALLON '36 NUMBER OF COMPARTt•.tELJT'S 457 <br /> AODTTONAL DESCRUMON(F lm wly) U 438 <br /> IL TANK CONTENTS ' <br /> TANK USE 439 P- OLEUM TY?E - ..0 <br /> I. MOTOR VEHICLE FUEL Is. REOULAR UNLEADED ❑2. LEADED ❑S. JET FUEL <br /> IB...k.4wawPwaW.Tap) C3 1b. PREMIUM UNLEADED [3 3. DIESEL ❑6. AVIATION FUEL <br /> ❑2. NON-FUEL PETROLEUM Cl Ic. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER <br /> ❑J. CHEMICAL PRODUCT COMMON NAME 16m Hmldw.kH�.bl.b.m..y rrl NI CASE<6m w..w..M.l=i.l.bwn.ry Mr 1 "3 <br /> ❑4. HAZARDOUS WASTE <br /> (b.krw Uw Oil) <br /> ❑95.UNKNOWN <br /> M. TANK CONSTRUCTION <br /> TYPE OF TANK I. SINGLE WALL U S. SINGLE WALL WITH 5. SINGLE WALL WITH INTERNAL BLADDER SYSTCM u3 <br /> (C1d...:..«17) EXTERIOR MEMBRANE LINER ^'095. UNKNOWN <br /> 2. DOUBLE WALL ❑4. SIGNLE WALL IN VAULT ❑99. OTHER <br /> I TANK MATERIAL- Uiaq IBERGLASSi PtASTC 0 5. CONCRETE Ej 95. UNKNOWN -4 <br /> i5..l w..®why <br /> Cl 2. STAINLESS STEEL. 04. STEEL CLAD W/FIBERGLASS ❑0. FRP COMPTIBLE W/1001/.METHANOL 099.OTHER <br /> REINFORCED PLASTIC(FRP) <br /> 4 <br /> TA NK MATERIAL-.m4.ylwk 1. BARE STEEL FIBERGLASS I PLASTIC S. CONCRETE 95. UNKNOWN us <br /> (o.u....m«h) ❑2. STAINLESS STEEL ❑4. STEEL CUD W/F10RGU55 ❑s. FRP COMPTIBLE W/100%NtETIIANOL ❑99.OTHER <br /> REINFORCED PLASTIC(FRP) ❑10.COATED STEEL <br /> ❑5. CONCRETE <br /> TANK INTERIOR LINING 1.RUBBER LINED J.EPDXY LINING 5.GLASS LINING 95,UNKNOWN 4M DATE INSTALLED 447 <br /> OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING 6CDNLINFD ❑99 OTHER <br /> (n=kw k.nsly) IF.,bwl m«hl <br /> I MANUFACTURED CATHODIC 7 FIBERGLASS REINFORCED PLASTICUNKNOWNua DATE INSTALLED a9 <br /> OTHER CORROSION ❑ ❑95 <br /> PROTECTION IF APPLICABLE PROTECTION ❑4IMPRESSED CURRENT ❑99 OTHER <br /> Icwckmk.=«h) ❑2 SACRIFICIAL ANODE fF..b«i"-ear5 <br /> SPILLANDOVR ILL YEARIN5TALLED 450 TYPE(l.ulmwly) 411 OVERFILL PROTECTION EQUIPMENT:YFAR INSTALLED 152 <br /> (Cb..k Jl b.S qph) I SPILL CONTAINMENT ❑1 ALARM <br /> ❑7 FILL TUBE SHUT OFF VALVE <br /> 2 DROP TUBE ❑2 BALL FLOAT ❑4 EXEMPT <br /> 3 STRIKER PLATE <br /> IV.TANK LEAK DETECTION(A a.e.p..etr..sk...s r.es••.k•u r wkmi.l leer l.rl.s«.1/) <br /> IF SINGLE WALL TANK(@ k.R wl m10 'S5 IF DOUBLE WALL TANK OR TANK WITH BLADDER <br /> (Ck km k..17) <br /> ❑ I VISUAL(EXPOSED PORTION ONLY) ❑S MANUAL TANK GA UGING(MTG N ❑I VISUAL(SING LE WALL IN VA ULT ONLY) <br /> ❑2 AUTOMATIC TANK GAUGING(ATG) ❑6 VADOSE ZONE >1 2 CONTINUOUS INTERSTITIAL MONITORING <br /> ❑5 CONTINUOUS ATG ❑7 GROUNDWATER ❑ NUAL MONITORING <br /> ❑4 STATISTICAL INVENTORY RECONCILIATION ❑t TANK TESTING <br /> (SIR) BIENNIAL TANK TESTING 0 9 OTHER <br /> TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> MATED DA[E T USED(YR/MO/DAY) 35 FSTIMAjED QUANTITY OF SUBSTANCE REMAINING 'f6 TANK FILLED WITH INERT MATERIAL? 457 <br /> 1., D �- (� gsllans ❑ Yes ❑ No <br /> UPCF(12/99 revised) 10 Formerly S W RCB Form B <br />