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13 <br /> ..._;FIED PROGRAM CONSOLIDATED FCS <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - TANK PAGE 1 <br /> (two pages per tank) <br /> Page Tof <br /> TYPE OF ACTION ❑1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE <br /> (Check one itrn only) ❑ 7 PERMANENTLY CLOSED ON SITE <br /> ❑ 3 RENEWAL PERMIT (Specilyreasan-forlocatmemly) (Speelfyreawn-fwlwalmcmly) ❑ 8 TANK REMOVED 430 <br /> BUSINESS NAME(Sameu FACILITYNA or DBA-Doingeusineati) FACILITYID: I <br /> A� 3 <br /> LOCATION WITHIN SITE(optional) 431 <br /> 315►b r-_a 1 ArANIY1L A)� S�oeICTd�I <br /> I.TANK DESCREPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local agency.) <br /> TANK ID# 433 TANK <br /> (AlNUF CoTURER`/ 433 COMPARTMENTALIZED TANK Yes No 434 <br /> I QI eiLJ J ��R ��(Nl If'Ya,co nPlae one Peso fa each comWrvnens. <br /> DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 <br /> 1x 1L <br /> ADDITIONAL DESCRIPTION(Fw IOW one only) 439 <br /> 11.TANK CONTENTS <br /> TANK USE 639 PETROLEUM TYPE 440 <br /> 'Al. MOTOR VEHICLE FUEL T Ia. REGULAR UNLEADED ❑2. LEADED ❑S. JET FUEL <br /> (If meted complete Pone].Tm) ❑Ib. PREMIUM UNLEADED 03. DIESEL ❑6. AVIATION FUEL <br /> ❑2. NON-FUEL PETROLEUM ❑Ic. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER <br /> ❑3. CHEMICAL PRODUCT COMMON NAME (from Haardoor Materials lnvmtwy page) 401 CAS#(from Ha.Son lNacrials lnvrntory Page) 442 <br /> ❑4. HAZARDOUS WASTE <br /> (Includes Ueed Oil) <br /> ❑95.UNKNOWN <br /> ID. TANK CONSTRUCTION <br /> TYPE OF TANK ❑1. SINGLE WALL 3. SINGLE WALL WITH 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 <br /> (Check me item only) EXTERIOR MEMBRANE LINER ❑95. UNKNOWN <br /> t*2. DOUBLE WALL [14. SIGNLE WALL IN VAULT ❑99. OTHER <br /> TANK MATERIAL-pUnry rank ❑L BARE STEEL 3. FIBERGLASS/PLASTIC S. CONCRETE 95. UNKNOWN 444 <br /> ((Meck me imn only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FMERGLASS [18. FRP COMPTIBLE W/100 METHANOL ❑99.OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-secondary tank 0 1. BARE STEEL OP. FIBERGLASS/PLASTIC 0 S. CONCRETE 95. UNKNOWN 445 <br /> (@erJc meitem only) ❑2. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPTIBLE W/100%METHANOL ❑99.OTHER <br /> REINFORCED PLASTIC(FRP) ❑10.COATED STEEL <br /> [IS. CONCRETE <br /> TANK INTERIOR LINING ❑1.RUBBER LINED ❑3.EPDXY LINING Cj S.GLASS LINING 95.UNKNOWN 446 DATE INSTALLED 447 <br /> OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING ❑6 UNLINED ❑99 OTHER <br /> (Chen mw item only) ,,aa,,// (Fon Intal use only) <br /> OTHER CORROSION [IIp, <br /> 1 MANUFACTURED CATHODIC 3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN 448 u9 <br /> PROTECTION IF APPLICABLE PROTECTION [14 IMPRESSED CURRENT ❑99 OTHER <br /> (Check me item only) ❑2 SACRIFICIAL ANODE (Fon IoW me only) <br /> SPILL AND OVERFILL YEAR INSTALLED Qp 450 TYPE(local use only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 <br /> (Checlt an mar apply) �tl SPILL CONTAINMENT 11 ALARM K3 FILL TUBE SHIT OFF VALVE <br /> OA2 DROP TUBE ❑2 BALL FLOAT ❑4 EXEMPT <br /> CM 3 STRIKER PLATE <br /> IV.TANK LEAK DETECTION MA de ripuonofthemmbnring programshall besubmittedtothe Inial agency.) <br /> IF SINGLE WALL TANK(check nil mar apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 651 <br /> Chock one item only) <br /> ❑1 VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MTG) ❑I VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑2 AUTOMATIC TANK GAUGING(ATG) ❑6 VADOSE ZONE 3 CONTINUOUS INTERSTITIAL MONITORING <br /> ❑3 CONTINUOUS ATG ❑7 GROUNDWATER ❑3 MANUAL MONITORING <br /> ❑4 STATISTICAL INVENTORY RECONCILIATION ❑8 TANK TESTING <br /> (SIR) BIENNIAL TANK TESTING ❑99 OTHER <br /> IV.TANK CLOSURE INFORMATION/PERNIANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YR/MO/DAY) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 459 <br /> zallons []Yes ❑ No <br /> UPCF(1/99 revised) r`/ 173 `.d Formerly SWRCB Form B <br />