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Iva <br /> l/ve- <br /> bwtFlED PROGRAMCONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 1 TANKS <br /> -/ saass <br /> (two ea per tank) <br /> TYPE OF ACTION SITE PERMIT ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑6 TEMPORARY SITE CLOSURE � <br /> ❑ 7 PERMANENTLY CLOSED ON SITE <br /> ❑ 3 RENEWAL PERMIT (Spcu%rtuw-forlwelum mly) (SP--*--f-b -oel <br /> r) ❑ 8 TANK REMOVED 430 <br /> BUSINESS NAME( F aI.TY DBA-Doing Butlrcaetu) 3 FACILITY ID: <br /> car ©F '° � o�✓ <br /> LULAI ION WITHIN SITE(Op n ) <br /> 431 <br /> L TANK DESCRtp'1'ION (A scaled Plot Plan With the loention of the UST system including buildings and landmarks shall be submitted to the local agency.) <br /> TANK ID# I 'A 432 fTANK MANUpACTU au COMPARTMENTALIZED TANK Ye o u4 <br /> DATE INSTALLED 433 ����"� urr��1fz`�'0w9efw«hi- <br /> (YEAR/MO) TANK CAPACITY IN GALLONS 4M NUMBER OF C?QW7 �� 437 <br /> -30 <br /> ADDITIONAL DESCRPTION(Por lau o ay) <br /> IL TANK CONTENTS <br /> TANK USE 439 PETROLEUM TYPE <br /> ❑L MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL <br /> (I(madNampb4s Pewld®Ty ) ❑Ib. PREMIUM UNLEADED 03. DIESEL ❑6. AVIATION FUEL <br /> ❑2.NON-FUEL PETROLEUM ❑la MIDGRADE UNLEADED ❑4. GASOHOL .OTHER <br /> ❑3.CHEMICAL PRODUCT COMMON NAME (bm llazodow M.miW Msmimy was) Ml CASk(6osa Wardo�uMewiala lvvmmypaae) 442 <br /> ❑4. HAZARDOUS WASTE <br /> �m�Da)yf�l <br /> ❑95.UNKNOWN DSC <br /> IR. TANK CONSTRUCTION <br /> TYPE OF TANK 050INGLE WALL U3. SINGLE WALL WITH 0 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> (Cha .aanooy) EXTERIOR MEMBRANE LINER [3 95. UNKNOWN <br /> ❑2. DOUBLE WALL [34. SIGNLE WALL IN VAULT (399. OTHER <br /> TANKMATERIAL-Pr®sry . BARE STEEL U 3. FIBERGLASS/PLASTIC Lj 5. CONCRETE U 95. UNMOWN 444 <br /> (Cheticaw 0m w%) ❑2. STAINLESS STEEL [34. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPIIBLE W/100%METHANOL ❑99 OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-axoa)uy mkU 1.BARE STEEL Q 3. FIBERGLASS/PLASTIC 0 5. CONCRETE U 95. UNKNOWN 40 <br /> (CLsn ow ism oery) <br /> 02. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGI.ASS ❑8. FRP COMPTIBLE W/100%METHANOL ❑99.OTHER <br /> REINFORCED PLASTIC(FRP) ❑10.COATED STEEL <br /> 05.CONCRETE <br /> TANK INTERIOR LINING OLRUBBERLINED U 3.EPDXY LINING 0 5.GLASS LINING Ll 95.UNKNOWN o46 DATE INSTALLED 447 <br /> OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LININGINED [3 99 OTHER <br /> (CMotaae ism m%) !ll��� (Fa local ws oob') <br /> 448 aN <br /> OTHER CORROSION [31 MANUFACTURED CATHODIC [33 FIBERGLASS REINFORCED PLASTIC�ASiJNKNOWN DATE INSTALLED <br /> PROTECTION IF APPLICABLE PROTECTION ❑4IJPItESSED CURRENT ❑99 OTHER <br /> (Chrkaosi=osly) ❑2 SACRIFICIAL ANODE (FwbW oaly) <br /> SPIT AND OVERFILL YEAR INSTALLED 43a TYPE bwl use odY) 451 OVERFILL PROTECTION EQUIP YEAR INSTALLED 491 <br /> (C W mumps%) ❑1 SPILL CONTAINMENT ❑1 ALARM ❑3 FILL TUBE SHUT OFF VALVE <br /> ❑2 DROP TUBE L2 ❑2 BALL FLOAT / ❑4 EXEMPT <br /> ❑3 STRIKER PLATE <br /> N.TANK LEAK DETECTION(A dmsnwim ofda;mooisming wow®smu be wumisrce sa lae)ocN gmcy.) <br /> IF SINGLE WALL TANK(Cres w mu. ly) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 4M4 <br /> (Chmasoeismon%) <br /> AL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MTG) ❑1 VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑2 AUTOMATIC TANK GAUGING(ATG) ❑6 VADOSE ZONE ❑2 CONTINUOUS INTERSTITIAL MONITORING <br /> ❑3 CONTINUOUS ATG ❑7 GROUNDWATER ❑3 MANUAL MONITORING <br /> ❑4 STATISTICAL INVENTORY RECONCILIATION ❑8 TANK TASTING <br /> (SIR) BIENNIAL TANK TESTING ❑99 OTHER <br /> N.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED TE LAS U ED(YR/MO/DAY) 4" ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 <br /> gallons ❑Yee o <br /> UPCF(12/99 revised) t0 Formerly SWRCB Form B <br />