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Te 1/7/79 UNIFIED PROGRAM CONSOLIDATED FORM `�� n TANKS "a M4-j F"v UNDERGROUND STORAGE TANKS - TANK PAGE 1 �rsld e- - (Two pages per tank) Page_of TYPE OF ACTION ® 1.NEW PERMIT ❑ 4.AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430. (Check one item mly) ❑ 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE (Specify reason) (Speciryrvsan) ❑ 8.TANK REMOVED BUSINESS NAME(same as FACILITY NAME m DBA-Doing Business As7 3. FACILITY ID: 1. Costco Gasoline Station /gf1A/IECq eft LOCATION WITHIN SITE(opdocs0 431. 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# 432. TANK MANUFACTURER 433. COMPARTMENTALIZED TANK ❑Yes ® No 434. 1 _ Containment Solutions If"Yee,"wmplete one page for each compartment. DATE INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS 437 (YEAR/MO) 30,000 1 ADDITIONAL DESCRIPTION(For I«a1 use Doty) 43& II.TANK CONTENTS TANK USE 439. PETROLEUM TYPE 440. M 1. MOTOR VEHICLE FUEL ®7a, REGULAR UNLEADED ❑2. LEADED [15. JET FUEL (If checked,completc Petroleum Type) ❑lb. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑ It. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME (from Harardom Materials Inventory page) 44L CAS#(fiam H&esmhus Mamriaa Inv=wgpage) 442. ❑ 4. HAZARDOUS WASTE (Includes used OR) petroleum Hydrocarbon, Unleaded Gasoline 8006-61-9 ❑ 95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK [11. SINGLE WALL [13. SINGLE WALL WITH EXTERIOR [15. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. (Check one item only) MEMBRANE LINER [195.UNKNOWN ®2. DOUBLE WALL [14. SINGLE WALL IN A VAULT ❑99. OTHER TANK MATERIAL-primary tank ❑1. BARE STEEL Ll 3. FIBERGLASS/PLASTIC 5. CONCRETEC195 .UNKNOWN 444. (Check ane item amy) ❑2. STAINLESS STEEL [14, STEEL CLAD W/FIBERGLASS ®8. FRP COMPATIBLE [199,OTHER: REINFORCED PLASTIC FRP W/100%METHANOL k [11.TANK MATERIAL-secondary ranks BARE STEEL 3. FIBERGLASS/PLASTIC 8. FRP COMPTIBLE W/100%METHANOL 0 95.UNKNOWN 445. (Check one item only) [12. STAINLESS STEEL❑4. STEEL CLAD W/FIBERGLASS ❑9. FRP NON-CORRODABLE JACKET [199,OTHER REINFORCED PLASTIC(FRII ❑10. COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING ❑1.RUBBER LINED [13.EPDXY LINING 5.GLASS LINING [195.UNKNOWN 446. DATE INSTALLED 447. OR COATING ❑2.ALKYD LINING ❑4.PHENOLIC LINING ®6.UNLINED [199.OTHER Check Doc item onl OTHER CORROSION [11.MANUFACTURED CATHODIC 99 3.FIBERGLASS REINFORCED PLASTIC ❑95.UNKNOWN 448. DATE INSTALLED 449. PROTECTION PROTECTION ❑4.IMPRESSED CURRENT [199.OTHER (If Applicable) 2.SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED 450. TYPE 451. OVERFILL PROTECTION EQUIPMENT: YEARINSTALLED 452. (Check all that apply) ®1.SPILL CONTAINMENT 2008 ®1.ALARM 2 00 8❑3.FILL TUBE SHUT OFF VALVE ®2.DROP TUBE TuuiF - ®2.BALL FLOAT 200804.EXEMPT ®3.STRIKER PLATE 20H- IV.TANK LEAK DETECTION (A description of the monitoring program shall be submitted to the local agency.) IF SINGLE WALL TANK 453. IF DOUBLE WALL TANK OR TANK WITH BLADDER 454. (Check all that apply) (Check one item only) ❑1.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 [3 99. OTHER V.TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YRMIOIDAY) 455' ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456' TANK FILLED WITH INERT MATERIAL? 457' gallons ❑Yes ❑ No UPCF hwfwrc-b(1/99)-1/4 www.unidocs.org Rev.02/16/00