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IFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 <br /> (two pages per tank) <br /> Paae�or <br /> TYPE OF ACTION ❑1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION 0,6 TEMPORARY SITE CLOSURE <br /> (Lteckaoc itemanly) ❑ 7 PERMANENTLY CLOSED ON SITE <br /> ❑ 3 RENEWAL PERMIT ❑ STANK REMOVED 430 <br /> BUSINESS NAME(Sann,m FACRITYNAM wDBA-Dons Bminrss Aa) FACILITYID: I <br /> 3 <br /> LOCATION WITHIN SI (optional) 431 <br /> L TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local agency.) <br /> TANK ED(�# �" 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK Yes No 434 <br /> )1 " fP(,/00L bLgz V(� B"Y®'.wmPlde ox paee(mcec6 cnnWamnmt <br /> DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 <br /> !F400L) <br /> ADDITIONAL DESCRIPTION(Fm kcal we only) 439 <br /> II.TANK CONTENTS <br /> TANK USE 439 PETROLEUM TYPE <br /> d 4w <br /> pp A MOTOR VEHICLE FUEL ❑Is. REGULAR UNLEADED ❑T�2�. LEADED ❑5. JET FUEL <br /> pfnewk wmpke Petmkmn Type) ❑Ib. PREMIUM UNLEADED W. DIESEL 06. AVIATION FUEL <br /> ❑2. NON-FUEL PETROLEUM ❑Ic. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER <br /> ❑3. CHEMICAL PRODUCT COMMON NAM E (from u.nione Mauriala inventory pose) 101 CAS#(tonne Hammlons Mmeriab lovera.,case) 442 <br /> [14. HAZARDOUS WASTE <br /> (4 Judet deed Oil) <br /> ❑95.UNKNOWN <br /> IH. TANK CONSTRUCTION <br /> TYPEOFTANK Lj I. SINGLE WALL U 3. SINGLE WALL WITH U 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 <br /> (Check <br /> one item only) EXTERIOR MEMBRANE LINER 095. UNKNOWN <br /> 9L. DOUBLE WALL ❑4. SIGNLE WALL IN VAULT ❑99. OTHER <br /> TANK MATERIAL-primary funk U 1. BARE STEEL U 3. FIBERGLASS/PLASTIC U 5. CONCRETE LEW. UNKNOWN 444 <br /> (Check mm loan only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑S. FRP COMPTIBLE W/100%METHANOL [199.OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-sero.duyook U 1. BARE STEEL U 3. FIBERGLASS/PLASTIC LJ S. CONCRETE . UNKNOWN 445 <br /> (Click one iwn only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPTIBLE W/100%METHANOL ❑99.OTHER <br /> REINFORCED PLASTIC(FRP) ❑10.COATED STEEL <br /> ❑5. CONCRETE <br /> TANK INTERIOR LINING 1.RUBBER LINED 0 3.EPDXY LINING 0 5.GLASS LINING 5.UNKNOWN 446 DATE INSTALLED U7 <br /> OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING ❑6 UNLINED ❑99 OTHER <br /> ((heck one ikon only) (Forlaralu only) <br /> OTHER CORROSION ❑I MANUFACTURED CATHODIC ❑3 FIBERGLASS REINFORCED PLASTICS UNKNOWN 41B DATE INSTALLED 449 <br /> PROTECTION IF APPLICABLE PROTECTION ❑4IMPRESSED CURRENT ❑99 OTHER <br /> (Check one ikon only) ❑2 SACRIFICIAL ANODE (Far Mcal=only) <br /> SPILL AND OVERFILL YEARINSTALLED 4 _45-0��' TYPE(loral•<-anly) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLEDn 452 <br /> (C kallthatapply) I&I SPILL CONTAINMENT lffik~t1 QJ ALARM ❑3FILL TUBE <br /> WWSIIHI�ITO FIVALVE <br /> R2 DROP TUBE ❑2 BALL FLOAT ❑4 EXEMPT <br /> [?'t-STRIKER PLATE <br /> IV.TANK LEAK DETECTION(A dncriptionofthe aw worins pm9xain shall be wbmined a me Iocel asoncy.) <br /> IF SINGLE WALL TANK(check dl mat apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 <br /> Rack one none only) <br /> ❑I VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MTG) k "I VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑2 AUTOMATIC TANK GAUGING(ATG) ❑6 VADOSE ZONE T�s[�CONTINUOUS INTERSTITIAL MONITORING <br /> ❑3 CONTINUOUS ATG ❑7 GROUNDWATER /a'Y MANUAL MONITORING <br /> ❑4 STATISTICAL INVENTORY RECONCILIATION ❑8 TANK TESTING <br /> (SIR) BIENNIAL TANK TESTING 0 9 OTHER <br /> IV.TANK CLOSURE INFORMATION 1 PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YR/MO/DAY) 455 ESTIMATED trITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 <br /> 2-02 lJ gallons 9,Ycs ❑ No <br /> UPCF(12/99 revised) 10 Formerly SWRCB Form B <br />