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/ ps <br /> b <br /> —NIFIED PROGR CM CONSOLIDATED Form Q� <br /> UNDERGROUND STORAGE TANKS - TANK PAGE I T �\ <br /> (two pages <br /> �.S- <br /> TYPE OF ACTION 131 NEW SITE PER" 136 AMENDED PERMIT 'R 5 CHANGE OFF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE <br /> (Sri a.o Sly) -/ u W-°-� ❑ 7 PERMANENTLY CLOSED ON SITE <br /> ❑ 3 RENEWAL PERMIT I TANK REMOVED cw <br /> BUSQJFSSNAba(U--FACMMKAME-o -�'�m) y FACILRYfD: fir . <br /> R Q LO 0 O �s 5itl <br /> LOCATION WITHIN SITE(oP•—') ah <br /> L TANK DESCRIPTION (A soled plot plan With the location of the UST system including buildings and landmarks shall be submitted to theIonil agcy) <br /> TANK IDM �= TANK MANUFACTURER 433 COMPARTMENTALIZED TANK Ya o 4 . <br /> bXe KeQa VYa:aakc.me was far.a m.P•n.•n. <br /> DATE INST (YEAR/MO) a55 TANK CAPACITY IN GALLONS °56 NUMBER OF COMPART S 437 <br /> b0 <br /> ADDITIONAL DESCRIPTION(F-—1 r vy) 438 <br /> IL TANK CONTENTS ' <br /> TANK USE iJ9 PETROLEUM TYPE <br /> I. MOTOR VEHICLE FUEL ❑la REGULAR UNLEADED ❑2. LEADED ❑S. JET NEL <br /> (urkr ra•yl..Pm.Wn Ty ) Ib. PREMIUM UNLEADED 03. DIESEL 06. AVIATION NEL <br /> ❑2. NON-NEL PETROLEUM P ❑Ic. MIDGRADE UNLEADED ❑i. GASOHOL ❑99.OTHER <br /> ❑3. CHEMICAL PRODUCT COMMON NAME(fir hl.•.N.u.Maul.I..r.•y r•e°I Mt CASII(f®Nu+•da•.Muai•I•Vrasl°ry P•M) �_ <br /> ❑6. HAZARDOUS WASTE <br /> (I. .uW Oil) <br /> ❑95.UNKNOWN <br /> M. TANK CONSTRUCTION <br /> TYPEOFTANK I. SINGLE WALL 0 3. SINGLE WALL WITH 0 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 <br /> t(,5 r:w.slyl EXTERIOR MEMBRANELINER 095. UNKNOWN <br /> 2. DOUBLE WALL ❑6. SIGNLE WALL IN VAULT ❑99. OTHER <br /> I TANK MATERIAL . BARBS EEL FIBERGLASS i PLASTC 0 5. CONCRETE 95. UNKNOWN aa. <br /> ❑2. STAINLESS STEEL' ❑a. STEEL CLAD WfF1BERGLASS ❑I. FRP CDMPTIBLE Wit 00%METHANOL ❑99.OTHER <br /> REINFORCED PLASTIC(FRP) <br /> I TANK MATERIAL-dnrk U L BARE STEEL VLN FIBERGLASS/PLASTIC 0 S. CONCRETE U 95. UNKNOWN aa5 <br /> ❑2. STAINLESS STEEL 06. STEEL CLAD W/RBERGLASS ❑I. FRPCOMPTIBLE W110011.METHANOL ❑99.OTHER <br /> I REINFORCED PLASTIC(FRP) ❑10.COATED STEEL <br /> ❑5. CONCRETE <br /> TANK INTERIOR LINING L RUBBER LINED 03,EPDXY LINING J��f„y65.GLASS LINING 95.UNKNOWN u6 DATE INSTALLED 447 <br /> M <br /> OR COATING ❑2 ALKYD LINING ❑6 PHENOLIC LING 6tNLINFD ❑99 OTHER <br /> last w sa.slyl IF.bun <br /> OTHER CORROSION ❑ 1 MANUFACTURED CATUNKNOWNus DATE INSTALLED <br /> 7 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOW <br /> PROTECTION IF APPLICABLE PROTECTION ❑A IMPRESSED CURRENT ❑99 OTHER <br /> ICkack as:em a,lyl ❑2 SACRIFICIAL ANODE fr^•IO•'�1f wlyl <br /> uo ul OVERFILL PROTECTION EQUII'MENT:YFAR INSTALLED as= <br /> SPILL AND OVERFILL YEARINSTALLED TYPE(bran,,..a•M <br /> laa .Il nn wybl I SPILL CONTAINMENT 0 ALARM ❑3 FILL TUBE SHUT OFF VALVE <br /> 2 DROP TUBE ❑2 BALL FLOAT ❑a EXEMPT <br /> 3 STRIKER PLATE <br /> IV.TANK LEAK DETECTION IA e..vo.—fs...°..—I IMS..ma <br /> I F SINGLE WALL TANK I ..nwuwbl .53 IF DOUBLE WALL TANK OR TAFI WITHBLADDER '6' <br /> (S k..a tema Iy) <br /> ❑ 1 V15UAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MTGN ❑ I VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑2 AUTOMATIC TANK GAUGING(ATG) ❑6 VADOSE ZONE >1 2 COI TNUOUS INTERSTITIAL MONITORING <br /> ❑3 CONTINUOUS ATG ❑7GROUNDWATER ❑ NUALMONITORING <br /> ❑a STATISTICAL INVENTORY RECONCILIATION ❑1 TANK TESTING <br /> (SIR) BIENNIAL TANK TESTING 0 9 OTHER <br /> N.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED GATE LAST USED(YR/MO/DAY) a55 ESTIMATED QUANTITY OF SUBSTANCE REMAINING .5M1 TANK FILLED WITH INERT MATERIALI a17 <br /> gallons Cl Yes ❑ No <br /> UPCF(12/99 revised) 10 Formerly SWRCB Form B <br />