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UNILD PROGRAM CONSOLIDATED FORM 3srrE <br /> UNDERGROUND STORAGE TANKS - TANK PAG (twfa <br /> "TYPE OF ACTION ❑ I NEW SITE PERMIT ❑ 4AMENDLD PERMIT ❑ �CI IAN,L OF INFORMATION ❑ 6 TEMPORARY SITE C(Chock Doty aem o�Jy) ❑ 7 PERMANENTLY CLO [�(Specify reason-for tical use only) (speify reason-for 10a use only) ❑8TANK REMOVED �J❑ 3RENEWAL PERMIT � 7BUSINESS NAME(Same as FACILITY NAME m DBA-Opmg amines A:) 3 <br /> LIBERTY RURAL FIRE DISTRICT <br /> LOCATION WITHIN SITE(Optional) 431 <br /> PHONE <br /> 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.) <br /> TANK ID#41 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK ❑Yes ❑No 434 <br /> o If'Yes",conopletc,one page for wh co t. <br /> DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 <br /> 525 <br /> ADDITIONAL DESCRIPTION(Fm meal Tse only) 438 <br /> 11.TANK CONTENTS <br /> TANK USE 43y PETROLEUM TYPE 440 <br /> ® 1.MOTOR VEHICLE FUEL ❑ la.REGULAR UNLEADED ❑ 2.LEADED ❑ 5.JET FUEL <br /> (lfn ukdcosryktc Petmlcom Type) ❑ Ib.PREMIUM UNLEADED ® 3.DIESEL ❑ 6.AVIATION FUEL <br /> ❑ 2.NON-FUEL PETROLEUM ❑ lc MIDGRADE UNLEADED ❑ 4.GASOHOL ❑99.OTHER <br /> ❑3.CHEMICAL PRODUCT COMMON NAME(from Hux4om Materiels Inventory Page) 441 CASK(6om Hamrdom Materials Inventory page) 442 <br /> ❑4.HAZARDOUS WASTE <br /> (Iruludn Used 00) <br /> F195.UNKNOWN <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK ❑ I.SINGLE WALL ❑ 3.SINGLE WALL WITH ❑ S.SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 <br /> (Check one ftm only) EXTERIOR MEMBRANE LINER ❑95.UNKNOWN <br /> ® 2.DOUBLE WALL ❑ 4.SINGLE WALL IN VAULT ❑ 99.OTHER <br /> TANK MATERIAL-primary tank ❑ 1.BARE STEEL ❑ FIBERGLASS/PLASTIC ❑ 5.CONCRETE ❑95.UNKNOWN 444 <br /> (Check one dem only) ❑ 2.STAINLESS STEEL ❑ STEEL CLAD W/FBERGLASS ❑ 8.FRP COMPTIBLE W/100%METHANOL <br /> REINFORCED PLASTIC(FRP) ❑99,OTHER <br /> TANK MATERIAL-secondary lank ❑ 1.BARE STEEL [13.FIBERGLASS/PLASTIC ❑ 5.CONCRETE ❑ 95.UNKNOWN 445 <br /> (Check om item only) ❑ 2.STAINLESS STEEL [14.STEEL CLAD W/FBERGLASS ❑ 8.FRP COMPTIBLE W/100%METHANOL <br /> REINFORCED PLASTIC(FRP) ❑ 10.COATED STEEL ❑ 99.OTHER <br /> ❑5.CONCRETE <br /> TANK INTERIOR LINING ❑ ) RUBBER LVED ❑ 3.EPDXY LIVING ❑ 5.GLASS LINING ❑ 95.UNKNOWN 446 DATE INSTALLED 447 <br /> OR COATING <br /> (Check one am only) ❑2 ALKYD LINING El PHENOLIC LINING ❑ 6 UNLINED El 99.OTHER <br /> (Fm IOW use Doty) <br /> OTHER CORROSION ❑ 1 MANUFACTURING CATHODIC ❑ 3 FIBERGLASS REINFORCED PLASTIC ❑ 95 UNKNOWN 443 DATE INSTALLED 449 <br /> PROTECTION IF APPLICABLE PROTECTION <br /> (Check orc dem oNy) El IMPRESSED CURRENT El 99 OTHER <br /> El 2 SACRIFICIAL ANODE (Fm tical sac Dory) <br /> SPILL AND OVERFILL YEAR INSTALLED 450 TYPE(local use only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 <br /> (Cheek all that apply) ❑ I SPILL CONTAINMENT ❑ 1 ALARM ❑ 3 FILL TUBE SHUT OFF VALVE <br /> ❑ 2DROP TUBE ❑ 2BALL FLOAT ❑ 4EXEMPT <br /> ❑ 3 STRIKER PLATE <br /> IV.TANK LEAK DETECTION(A description of the monitoring xrogrun shalt he sudnntd to the hxa1 agency.) <br /> IF SINGLE WALL TANK(Check all that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 <br /> ❑ 1 VISUAL(EXPOSED PORTION ONLY) ❑ 5 MANUAL TANK GAUGING(MTG) (Check one item only) <br /> ❑ 2 AUTOMATIC TANK GAUGING(ATG) ❑ 6 VADOSE ZONE ❑ 1 VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑ 3 CONTINUOUS ATG ❑ 7 GROUNDWATER ®2 CONTINUOUS INTERSTITIAL MONITORING <br /> ❑4 STATISTICAL INVENTORY RECONCILIATION ❑ 8 TANK TESTING ❑3 MANUAL MONITORING <br /> (SIR)BIENNIAL TANK TESTING ❑ 99 OTHER <br /> V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YR/MO/DAY) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 <br /> gallons ❑Yes ❑No <br /> UPCF(12/99 revised) <br />