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UNIFIED PROGRAM CONSOLIDATED FORM TANK: TA0152904 PR#: PR0231528 UNDERGROUND STORAGE TANKS - TANK PAGE 1 FAC#: FA0003795 (two pages per k ° 5 t TYPE OF ACTION ❑ INEW SITE PERMIT ❑ 4.41tFNDED PERMIT ❑ 5C1IAN GE UFI%FORMA I[ON ❑ 6TEMPORARY SITE CLOS (Chs wIy imn my) ❑ 7 PERMANENTLY CLOSED SITE (spai%rusty-ra loaalux wry) (sv=airysusaa-rm loyal iac wty) STANK REMOVED 43 ❑ IRENEWAL PERMIT ❑ BUSINESS NAME(Same st FACILITY N"E m DBA-oobg emiama 1) FACILITY ID: PH#: D� LIBERTY RURAL FIRE DISTRICT 3 FA0003795 PR0231528 / LOCATION WITHIN SITE(opt 24124 N BRUELLA RD,ACAMPO 431 PHONE �nnd 1.TANK DESCRIPTION(A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted w Ute local agency.) V TANK ID# Tank#: 4 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK ❑Yes ❑No 434 TA0152904 IrYm,mrylme awva9=rmum mmparoams. DATE INSTALLED(YEAR/M0) 435 TANK CAPACITY INGALLONS 436 NUMBER OF COMPARTMENTS 437 525 ADDITIONAL DESCRIPTION(Far but memty) 439 H.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 4w ® L MOTOR VEHICLE FUEL ❑ Ia.REGULAR UNLEADED ❑ 2.LEADED ❑ 5.JET FUEL Ofsss dmmlaeP-I-Ty ) ❑ Ib.PREMIUM UNLEADED ® 3.DIESEL ❑6.AVIATION FUEL ❑ 2.NON-FUEL PETROLEUM ❑ )c,MIDGRADE UNLEADED ❑ 4.GASOHOL ❑99.OTHER ❑ 3.CHEMICAL PRODUCT COMMON NAME(6om Hssaniom mitim.h lmmimy page) 441 CAS#(6om Haarmus Mmaials lmcmdr page) 441 ❑4.HAZARDOUS WASTE ( sit 11a oil) El 95.UNKNOWN IO.TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ❑ 3.SINGLE WALL WITH ❑ S.SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Chale wciwa wy) EXTERIOR MEMBRANE LINER ❑ 95.UNKNOWN ® 2.DOUBLE WALL ❑ 4.SINGLE WALL IN VAULT ❑".OTHER TANK MATERIAL-psirnary tank ❑ I.BARE STEEL ❑ FIBERGLASS/PLASTIC ❑ 5.CONCRETE ❑ 95.UNKNOWN 444 (C i,tiaitari yp ❑ 2.STAINLESS STEEL ❑ STEEL CLAD W/FIBERGLASS ❑ 8.FRP COMPTIBLE W/IWA METHANOL REINFORCED PLASTIC(FRP) ❑ ".OTHER TANK MATERIAL-secondary tank ❑ I.BARE STEEL ❑ 3.FIBERGLASS/PLASTIC ❑ 5.CONCRETE ❑ 95.UNKNOWN 445 (Oh mm it.wy) ❑ 2.STAINLESS STEEL ❑4.STEEL CLAD W/FIBERGLASS ❑ a.FRP COMPTIBLE W/100%METHANOL REINFORCED PLASTIC(FRP) ❑ 10.COATEDSTEEL ❑ 99.OTHER ❑ 5.CONCRETE TANK INTERIOR LINING ❑ I.RUBBER LINED ❑ 3.EPDXY LINING ❑ 5.GLASS LINING ❑95.UNKNOWN a6 DATE INSTALLED u7 OR COAT NG (Citm mly) ❑ 2 ALKYD LINING ❑ 4 PHENOLIC LINING C] 6 UNLINED El 99.OTHER hs m= (Fmlanl w mty7 OTHERCORROSION ❑ I MANUFACTURING CATHODIC ❑3 FIBERGLASS REINFORCED PLASTIC E] 95 UNKNOWN Na DATE INSTALLED u9 PROTECTION IF APPLICABLE PROTECTION (Chale ws ism aaly) ❑4IMPRESSED CURRENT ❑ "OTHER ❑ 2SACRIFICIAL ANODE (Fa bratttscmy) SPILL AND OVERFILL YEAR INSTALLE450 TYPE(loul uumty) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Check all Jut apply) ❑ 1 SPILL CONTAINMENT ❑ )ALARM ❑ 3 FILL TUBE SHUT OFF VAL` ❑ 2 DROP TUBE ❑ 2 BALL ❑ 4 EXEMPT ❑ 3STRIKER PLATE FLOAT IV.TANK LEAK DETECTION(A baipew of mmittiv%vtwsm.nsII n=sahmitbd b JK tool ag=my.) IF SINGLE WALL TANK(C .fl Uat appy) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 ❑ I VISUAL(EXPOSED PORTION ONLY) ❑ 5 MANUAL TANK GAUGING(MTG) (Click am iim only) ❑ 2 AUTOMATIC TANK GAUGING(ATG) ❑6VADOSE ZONE ❑ I VISUAL(SINGLE WALL IN VAULT ONLY) ❑ 3 CONTINUOUS ATG ❑ 7 GROUNDWATER M 2 CONTINUOUS INTERSTITIAL MONITORING ❑4 STATISTICAL INVENTORY RECONCILIATION ❑ STANK TESTING ❑3 MANUAL MONITORING (SIR)BIENNIAL TANK TESTING ❑ 99 OTHER V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YWMOMAY) ass ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 ❑Yes ❑No UPCF(12/99 revised)