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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 (Two pages per tank) Page I of 2(removal) TYPE OF ACTION ❑ I.NEW PERMIT ❑ 4.AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430. (Chwk one item only) ❑ 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE (Specify maw.) (specify reason) ® 8.TANK REMOVED BUSINESS NAMES.as FACILITY NAME or DBA-Doing Boniness As) I. I FACILITY ID: 1. Pacific Bell 4 LOCATION WITHIN SITE(Optional) 431 See plans 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 p p�rs/43322. TANK MANUFACTURER d33. COMPARTMENTALIZED TANK ❑Yes ® No n4. 7l w V JOOC lasteel If"Yes,"complem one page for each compumanl. ATE INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS (YEAR/MO) 437. 1998 2,000 1 ADDITIONAL DESCRIPTION(For local use only) - 4J8. II.TANK CONTENTS TANK USE 439. PETROLEUM TYPE 44). ® L MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED ❑2. LEADED [15. JET FUEL (IfehxJctd,complete Natal.Type) ❑ Ib. PREMIUM UNLEADED ®3. DIESEL ❑6. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑Ic. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME (fiom Haardous Materials Inventory page) 601' CAS#(fivm Hnardova Material,loventory page) 442. ❑ 4. HAZARDOUS WASTE (Include Uaed Oil) ❑ 95.UNKNOWN 1111.TANK CONSTRUCTION TYPE OF TANK D I. SINGLE WALL 3. SINGLE WALL WITH EXTERIOR ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. (Check one item only) MEMBRANE LINER ❑95. UNKNOWN ®2. DOUBLE-WALL 4. SINGLE WALL IN A VAULT 99. OTHER TANK MATERIAL-pHatarywh ® 1, BARESTEEL ❑3. FIBERGLASS/PLASTIC 05. CONCRETE 095.UNKNOWN 444. (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE [199.OTHER: REINFORCED PLASTIC FRP W/100%METHANOL TANK MATERIAL-secondary tank 1. BARE STEEL [13. FIBERGLASS/PLASTIC 8. FRP COMPTIBLE W/100%METHANOL ❑95.UNKNOWN 445. (Check one item only) ❑2. STAINLESS STEEL ®4. STEEL CLAD W/FIBERGLASS ❑9. FRP NON-CORRODABLE JACKET [199.OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL [15. CONCRETE TANK INTERIOR LINING I.RUBBER LINED LI 3.EPDXY LINING 5.GLASS LINING 0 95.UNKNOWN 446. DATE INSTALLED 447. OR COATING ❑2.ALKYD LINING [14.PHENOLIC LINING ®6.UNLINED ❑99.OTHER 1988 Check one item only) OTHER CORROSION ❑L MANUFACTURED CATHODIC 3.FIBERGLASS REINFORCED PLASTIC ®95.UNKNOWN a8. DATE INSTALLED 449. PROTECTION PROTECTION [14.IMPRESSED CURRENT ❑99.OTHER 1988 (If Applicable) 2.SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED 450. TYPE 451. OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 452. (Check all that apply) ®I.SPILL CONTAINMENT 1998 ® I.ALARM (1998) 19 3.FILL TUBE SHUT OFF VALVE (1998) ®2.DROP TUBE 1998 [12.BALL FLOAT(1995) ❑4.EXEMPT ®3.STRIKER PLATE 1998 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) ❑I.VISUAL(EXPOSED PORTION ONLY) ❑S.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 [:17.GROUNDWATER ❑3.MANUAL MONITORING ❑4.STATISTICAL INVENTORY RECONCILIATION [:18.TANK TESTING (SIR)+BIENNIAL TANK TESTING [199.OTHER V.TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST U ED(YR/MO/DAY) 455. ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456. TANK FILLED WITH INERT MATERIAL? 411. Currently active 2 3 2,000 gallons Q [:]Yes ❑ No UPCF hwfwrc-b(1/99)-1/4 http://www.unidoes.org Rev.02/16/00