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%...,IIFIED PROGRAM CONSOLIDATED FORM 1110>- TANK: \'l III;JIQ PR p: UNDERGROUND STORAGE TANKS -TANK �-Y' FAC u: lb (two pages per tank) TYPE OF ACTION ❑ 1 NEW SITE PERMITPage 2 of3 (LTak a ynen only) ❑4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPoRARY SITE CLOSURE ® . ,TANK REMOVED PERMANENTLY LOSER ON SITE 430 (/ ❑ 3RENEWAL PERMIT /-� /1 ) / B()S I$ E( �y A(;RIIYNAMg wDBA-DamB Bu.06wfineff Av) I\e_ 3 ODV 3 YFACILITY om- OZ� 1 S/ t LOCATIO�1N,#Y'_JV1`WITfBN SITE(fg]DP''y('�imol�p�, � p ' -31 ; 1 `�F-/y r/t4 g'cJ/� PHONE e31 1.TANK DESCRIPTION(A scaled plot plan with the location ofthe UST system including buildings and landmarks stall be subnritted to the local agency.) TANK IDN J TAC)' I D UEl2 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK Yes El No 134 If"Y®'.campkKaoe WBe fmacb mmpaMimt DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GAIL NS 4311 NUMBER OF COMPARTMENTS 632 ADDITIONALDESCRIPTION(Fmt iouowy) Z 439 11.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 660 ❑ I.MOTORVEHICLE FUEL ❑ Ia.REGULAR UNLEADED ❑ 2.LEADED [15.JET FUEL (IfomkN Wef` pIman Tyye) ❑ Ib.PREMNM UNLEADED ❑ 3.DIESEL ❑6.AVIATION FUEL ❑ 2.NON-FUEL PETROLEUM ❑ It.MIDGRADE UNLEADED ❑ 4.GASOHOL ❑ ".OTHER ❑3.cFwmCAL PRODUCT COMMON NAME(6wn H.,&.m.0 .n Immlwywge) al CASH 11. m Mom h mvm(my page) 642 ❑4.HAZARDOUS WASTE p JWu u.dap ❑95.UNKNOWN III TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ❑ 3.SINGLE WALL WITH [15.SINGLE WALL WITH INTERNAL 13LADDER SYSTEM 443 ((Uckm ma0y) EXTERIOR MEMBRANE LINER El 95.UNKNOWN [12.DOUBLE WALL ❑ 4.SINGLE WALL IN VAULT ❑".OTHER TANK MATERIAL-primary tank ❑ I.BARE STEEL ❑ FIBERGLASS/PLASTIC ❑ S.CONCRETE ❑95.UNKNOWN 449 (Chd om item owy) ❑ 2.STAINLESS STEEL ❑ STEEL CLAD WTIBERGLASS ❑ 8.FRP COMPTIBLE W/100%METHANOL REINFORCED PLASTIC(FRP) ❑99.OTHER TANK MATERIAL-secondary tank ❑ 1.BARE STEEL ❑ 3.FIBERGLASS/PLASTIC ❑ 5.CONCRETE ❑ 95.UNKNOWN 465 (Cask arc nnn wry) ❑2.STAINLESS STEEL ❑4.STEEL CLAD W/FIBERGLASS ❑ 8.FRP COMPTBLE W/100%METHANOL REINFORCED PLASTIC(FRP) ❑ 10.COATED STEEL ❑99.OTHER ❑ 5.CONCRETE TANK INTERIOR LINING ❑ 1.RUBBER LINED ❑3.EPDXY LINING ❑ 5.GLASS LINING ❑95.UNKNOWN dm DATE INSTALLED 441 OR COATING (Cta "ftmi mly) ❑2 ALKYD LINING ❑4 PHENOLIC LINING ❑6 UNLINED ❑".OTHER (Pm kul merry) OTHER CORROSION ❑ 1 MANUFACTURING CATHODIC ❑ 3 FIBERGLASS REINFORCED PLASTIC ❑ 95 UNKNOWN 4411 DATE INSTALLED 449 PROTECTION IF APPLICABLE PROTECTION (L3e avamy) ❑2 SACRIFICIAL ANODE E:141MPRESSEDCURRENT E] 99 OTHER (for�11BeO1y) SPILL AND OVERFILL YEAR INSTALLE450 TYPE(b I.mdy) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (C aO am may) ❑ 1 SPILL CONTAINMENT ❑ I ALARM ❑ 3 FILL TUBE SHUT OFF VAL' ❑ 2 DROP TUBE ❑ 2 BALL ❑4 EXEMPT ❑ 3STRIKER PLATE FLOAT IV.TANK LEAK DETECTION(A dvmpaa.ordsamummgPmgtm.B.,eeaub,wndto roe muing I IF SINGLE WALL TANK(C aO Int appy) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 ❑ I VISUAL(EXPOSED PORTION ONLY) ❑ 5 MANUAL TANK GAUGING(MTG) (C me mm my) ❑2AUTOMATIC TANK GAUGING(AID) ❑ 6 VADOSE ZONE ❑ I VISUAL(SINGLE WALL IN VAULT ONLY) ❑3 CONTINUOUS ATG ❑ T GROUNDWATER [:12 CONTINUOUS INTERSTITIAL MONITORING ❑4 STATISTICAL INVENTORY RECONCILIATION ❑ STANK TESTING ❑3 MANUAL MONITORING (SIR)BIENNIAL TANK TESTING ❑ 99 OTHER V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED D LAST 4SED(YRIMO/DAY) 455 1 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 451 I TANK FILLED WITH INERT MATERIAL? 451 ❑Yea ❑No 10 UPCF(12/99 revised)