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UNI,D PROGRAM CONSOLIDATED FORM TANKS Ct - UNDERGROUND STORAGE TANKS - TANK PAGE a�(twD pages per tank) Page 8 of 13 TYPE OF ACTION ❑ 1 NEW SITE PERMIT ❑4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE I�I (Check only item only) - s+t' :` '`- ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3RENEWAL PERMIT 'lyff89O6fOr �eO ❑STANK REMOVED 430 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business At) 3 FACILITY ID: 1 LIBERTY RURAL FIRE DISTRICT LOCATION WITHIN SITE(Optimal) 431 PHONE L TANK DESCRIPTION(A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the Imal agency.) TANK ID# T z TANK MANUFACTURER 433 I COMPARTMENTALIZED TANK ❑yes ❑No 434 -rA D 15?vc) If"Yes".c Inc ow for each w DATE INSTALLED(YEAR/MO) 411 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 525 ADDITIONAL DESCRIPTION(For lwal use only) 438 II.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 ® 1.MOTOR VEHICLE FUEL ® la.REGULAR UNLEADED ❑2.LEADED ❑ 5.JET FUEL (Ifriarked corrykte Petroleum Type) ❑ Ib.PREMIUM UNLEADED ❑ 3.DIESEL ❑ 6.AVIATION FUEL ❑ 2.NON-FUEL PETROLEUM ❑ Ic.MIDGRADE UNLEADED ❑4.GASOHOL ❑ 99.OTHER ❑3.CHEMICAL PRODUCT COMMON NAME(from Hazardoos Materials Inventory page) 44l CAS#(6om Hazardous Materials Invwtory page) 442 ❑4.HAZARDOUS WASTE (Include Used W) ❑95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ❑ 3.SINGLE WALL WITH ❑5.SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one nem only) EXTERIOR MEMBRANE LINER El 95.UNKNOWN 912.DOUBLE WALL ❑4.SINGLE WALL IN VAULT ❑ 99.OTHER TANK MATERIAL-primary tank ❑ 1.BARE STEEL ❑ FIBERGLASS/PLASTIC ❑ 5.CONCRETE ❑ 95.UNKNOWN 444 (Chock one item only) ❑ 2.STAINLESS STEEL ❑ STEEL CLAD W/FBERGLASS ❑ 8.FRP COMPTIBLE W/100°/METHANOL REINFORCED PLASTIC(FRP) ❑ 99.OTHER TANK MATERIAL-secondary tank ❑ 1.BARE STEEL ❑ 3.FIBERGLASS/PLASTIC ❑ 5.CONCRETE ❑ 95.UNKNOWN 445 (Check om hem only) ❑ 2.STAINLESS STEEL ❑4.STEEL CLAD W/FBERGLASS [18.FRP COMPTIBLE W/100%METHANOL REINFORCED PLASTIC(FRP) ❑ 10.COATED STEEL ❑ 99.OTHER ❑ 5.CONCRETE TANK INTERIOR LINING ❑ L RUBBER LINED ❑ 3.EPDXY LINING ❑ 5.GLASS LINING ❑ 95.UNKNOWN 446 DATE INSTALLED M7 OR COATING (Check one nem only) El ALKYD LINING [:14 PHENOLIC LINING El UNLINED E:1 99.OTHER (For krral use only) OTHER CORROSION ❑ 1 MANUFACTURING CATHODIC ❑ 3 FIBERGLASS REINFORCED PLASTIC ❑ 95 UNKNOWN Ms DATE INSTALLED a9 PROTECTION IF APPLICABLE PROTECTION (Check ane nem only) El IMPRESSED CURRENT El 99 OTHER ❑ 2 SACRIFICIAL ANODE (Fro IorJl use Doty) SPILL AND OVERFILL YEAR INSTALLED 459 TYPE(tical me Doty) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Check an that apply) ❑ 1 SPILL CONTAINMENT ❑ 1 ALARM ❑ 3 FILL TUBE SHUT OFF VALVE ❑ 2DROP TUBE ❑ 2BALL FLOAT ❑ 4EXEMPT [-13 STRIKER PLATE IV.TANK LEAK DETECTION(A description ofthe monitoring program shall he subndneci to the local agmnv ) IF SINGLE WALL TANK(Check all that awry) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 ❑ 1 VISUAL(EXPOSED PORTION ONLY) ❑ 5 MANUAL TANK GAUGING(MTG) (Check one den only) ❑2 AUTOMATIC TANK GAUGING(ATG) ❑ 6 VADOSE ZONE ❑ I VISUAL(SINGLE WALL IN VAULT ONLY) ❑ 3 CONTINUOUS ATG ❑ 7 GROUNDWATER ®2 CONTINUOUS INTERSTITIAL MONITORING ❑4 STATISTICAL INVENTORY RECONCILIATION ❑ 8 TANK TESTING ❑3 MANUAL MONITORING (SIR)BIENNIAL TANK TESTING [:199 OTHER V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 455 1 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 gallons ❑Yes ❑ No UPCF(12/99 revised)