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VIED PROGRAM CONSOLIDATED FO TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 (two pagr P ) Of TYPE OF ACTION ❑ 1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT [15 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE O - (Check one item Doty) ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT (Specifymeson-forlocaluseonly) (Specifymason-forlocal useonly) ❑ STANK REMOVED BUSINESS NAME(Same as FACILITY NAME m DBA -Doing Business As) 3 FACILITY ID: �� 1 1 USA GASOLINE #05 5 LOCATION WITHIN SITE (Optional) 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.) TANK ID # 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK []Yes N No 0 a 0-3 V4 MODERN WELDING If"Ya", complete one page fm each comparhnad. \� ATE INSTALLED (YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 12,000 1 ADDITIONAL DESCRIPTION (For lucaluse only) 438 H. TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 ® 1. MOTOR VEHICLE FUEL ® la. REGULAR UNLEADED [12. LEADED ❑ 5. JET FUEL (Ifmarked amPkte Peboleim Type) ❑ Ib. PREMIUMUNLEADED ❑ 3. DIESEL ❑ 6. AVIATIONFUEL ❑ 2. NON -FUEL PETROLEUM ❑ lc. MmGRADE UNLEADED [14. GASOHOL [199. OTHER ❑ 3. CHEMICAL PRODUCT COMMON NAME (from Hazardous Materials Inventory page) MI CAS# (from Hazardous Materiels Inventory page) 4d2 [14. HAZARDOUS WASTE (Inchides Used Off) ❑ 95. UNKNOWN III. TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL [13. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Checkaceitemonly) EXTERIOR MEMBRANE LINER 095. UNKNOWN ® 2. DOUBLE WALL ❑ 4. SIGNLE WALL IN VAULT [199. OTHER TANK MATERIAL-prharylack ®1. BARE STEEL 03. FIBERGLASS/PLASTIC ❑5. CONCRETE 095. UNKNOWN 444 (Check ane item only) ❑ 2. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS ❑ S. NEP COMPTIBLE W/100eA METHANOL 1199 OTHER REINFORCED PLASTIC (FRP) TANK MATERIAL -secondary tack [11. BARESTEEL 03. FIBERGLASS/ PLASTIC 05. CONCRETE ❑95. UNKNOWN 445 (Chak orrerta c ady) ❑ 2. STAINLESS STEEL 04. STEEL CLAD WNIBERGLASS ❑ S. FET COMPTIBLE W/100 METHANOL ❑ 99. OTHER REINFORCED PLASTIC (FRP) [110, COATED STEEL ❑ 5. CONCRETE TANK INTERIOR LINING 1. RUBBER LINED 3. EPDXY LINING El 5. GLASS LINING 0 95. UNKNOWN 446 DATE INSTALLED 447 OR COATING ❑ 2 ALKYD LINING ❑ 4 PHENOLIC LINING ®6 UNLINED ❑ 99 OTHER (Checkosciterse.*) (Forlowluseonly) OTHER CORROSION ❑ 1 MANUFACTURP.D CATHODIC ❑ 3 FIBERGLASS REINFORCED PLASTIC ❑ 95 UNKNOWN PROTECTION IF APPLICABLE PROTECTION ❑ 4IMPRESSED CURRENT ❑ 99 OTHER (Checkoneitenronly) ❑ 2 SACRIFICIAL ANODE (FmloaluseoNy) SPILL AND OVERFILL YEARINSTALLED 450 TYPE (local use only) 451 OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 452 (check au Out apply) ® 1 SPILL CONTAINMENT 1997 ®1 ALARM 1997 ❑ 3 FILL TUBE SHUT OFF VALVE ® 2 DROP TUBE 1997 ® 2 BALL FLOAT 1997 ❑ 4 EXEMPT ® 3 STRIKER PLATE 1997 IV. TANK LEAK DETECTION (A daaipdonofthe monitoring program shall be submitted lathe local agency.) IF SINGLE WALL TANK(Check au rhatapply) d53 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 (Check one train a*) ❑ I VISUAL (EXPOSED PORTION ONLY) ❑ 5 MANUAL TANK GAUGING (MTG) ❑ 1 VISUAL (SINGLE WALL IN VAULT ONLY) ❑ 2 AUTOMATIC TANK GAUGING (ATG) ❑ 6 VADOSE ZONE ® 2 CONTINUOUS INTERSTITIAL MONITORING ❑ 3 CONTINUOUS ATG ❑ 7 GROUNDWATER ❑ 3 MANUAL MONITORING ❑ 4 STATISTICAL INVENTORY RECONCILIATION ❑ 9 TANK TESTING (SIR) BIENNIAL TANK TESTING ❑ 99 OTHER M. TANK CLOSURE INFORMATION / PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED (YR/MO/DAY) 455 ESTMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 gallons ❑ Yes ❑ No UPCF (1/99 revised) Formerly SWRCB Form B 10, V`