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•"W( 'IED PROGRAM CONSOLIDATED F(' �� TANKS ) UNDERGROUND STORAGE TANKS - TANK PAGE 1 (two pages per tank) TYPE OF ACTION ❑1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT 5 CHANGE OF INFORMATION. a 7 TEMPORARY E MANENTLY CLOSED ON SITE (Check one item only) !,'CT430 ❑ 3 RENEW AL PERMIT (Specify reason-for local use only) (Specify reaam-for local use Duly) ❑ 8 TANK REMOVED 1 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID: / i ` t�Y" © N t- 431 LOCATION (THIN SITE(Opptkmal) lullWzs 'T s e / S G /N 8�C{ , 1.TANK DESCRIPTION (A scaled plot plan with the location of e UST system including3 p1ItICOMPARTMENTALIZED TANK ed t Yes local agency.) ency 434 TANK ID# 432 TANK MANUFACTURER 50 G LC Q �� '. ) �Iex f If"Yes",complete one page for each 0romp+vment. ( V 4436 NUMBER OF COMPARTMENTS 43� DATE INSTALLED(YEA MO) 435 TANK CAPACITY IN GALLONS J� 7 5- 1? V s' `� 438 ADDITIONAL DESCRIPTION(For local use only) 1S %�•- /8_0 C _7 II.TANK CONTF.NCS 440 TANK USE 439 PETROLEUM TYPE �r_ 1. MOTOR VEHICLE FUEL Jr. REGULAR UNLEADED ❑2• LEADED ❑5. JET FUEL c � (If marked complete Petroleum Type) �'b. PREMIUM I7NLEADE& [13. UIESEL ❑6. AVIATION FUEL ❑2. NON-FUEL PETROLEUM ❑ Ic. MIDGRADE UNLEADED El4. GASOHOL ❑99 OTHER 442 441 CAS#(from tlazardous Materials Inventory page) ❑3. CHEMICAL PRODUCT COMMON NAME (fmnt Hazardous Materials Inventory page) ❑4. HAZARDOUS WASTE (Includes Used Oil) ❑95.UNKNOWN III. TANK CONSTRUCTION TYPE OF TANK ❑t. SINGLE WALL ❑3. SINGLE W ALL WITH ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 EXTERIOR MEMBRANE LINER ❑95. UNKNOWN (Check one item only) 99. OTHER DOUBLE WALL ❑4. SIGNLE W ALL IN VAULT ❑ 95. UNKNOWN 444 TANK MATERIAL-p:'- ,-,k 1. BARE STEEL ❑3. FIBERGLASS/PLASTIC 5. CONCRETE (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPTIBLE W/100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL- ry ook ❑1. BARE.STEEL ❑3. FIBERGLASS/PLASTIC ❑5. CONCRETE 95. UNKNOWN 445 ❑2. STAINLESS STEEL STEEL CLAD W/FIBERGLASS ❑8. FRP COMFrIBLE W/10096 METIIANOL ❑99.OTHER (Cl+eck one item only) 10.COATED STEEL REINFORCED PLASTIC(FRP) ❑ ❑5. CONCRETE 446 DATE INSTALLED 447 TANK INTERIOR LINING ❑t.RUBBER LINED ❑3.EPDXY LINING ❑5.GLASS LINING ❑95.UNKNOWN ❑2 ALKYD LINING ❑4 PHENOLIC LINING �UNLWED 99 OTHER (For tical use only) OR COATING (Check one item only) 446 44g OTHER CORROSION ❑1 MANUFACTURED CATHODIC FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN ❑4 IMPRESSED CURRENT ❑99 OTHER PROTECTION IF APPLICABLE PROTECTION (For local use only) (Check one item only) ❑2 SACRIFICIAL ANODE452 SPILL AND OVERFILL YEAR INSTALLED 450 'TYPE(focal use Doty) 451 OVERFILL PRO'CECTION F;QUIYMEN'1':YEAR INSTALLED [31 ALARM FILLTUBE SHUT OFF VALVE (Check all that apply) ,�1 SPILL CONTAINMENT ❑2 BALL FLOAT ❑4 EXEMPT DROP TUBE STRIKER PLATE IV.TANK LEAK DETECTION(A description of the monitoring program shall be suhn fitted to the local agency.) 4453 IF DOUBLE WALLTANKORTANK WITH BLADDER 454 FIFSIN,G-LE WALL TANK(Check all that aPPIY> (Cl eck one itan only) UAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MTG) ❑1 VISUAL(SWGLE WALL IN VAULT ONLY) 6 VADOSE ZONE CONTINUOUS INTERSTITIAL MONITORING TOMATIC TANK GAUGING(ATG) GROUNDWATER ❑3 MANUAL MONITORING NTINUOUS ATG ATISTICAL INVENTORY RECONCILIATION ❑8 TANK TESTING (SIR) BIENNIAL TANK TESTING ❑99 OTHER IV.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE 457 �455TIMATED QUANTITY OF SUBSTANCEREMAINING456 TANK FILLE�W�H ERT MATERIAL?ESTIMATED DATE LAST USED(YR/MO/DAgallons s ❑ No UPCF(1/99 revised) 173 Formerly SWRCB Form B