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91MD PROGRAM CONSOLIDATED FIV - TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 (two pages tank) Peg of TYPE OF ACTION ❑ 1 NEW SITE PERMIT ❑ 4 AMENDED PERMrT [15 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Check one item only) ❑ 7 PERMANENTLY CLOSED ON SITE [13 RENEWAL PERMIT (Specifymason-forlocd...1y) (Specifyreaon-forloc ...Iy) ❑ 8 TANKREMOVED BUSINESS NAME(Seme as FACILITY NAME or DBA- Doing Bminesa As) FACILITY ID: USA GASOLINE #65 3 3� 1X1 LOCATION WITHIN SrrE (optione0 10\431 yah L TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local agency.) ID # 432 TANK MANUFACTURER � COMPARTMENTALIZED TANK ® Yes ❑ No 434 4T�ANK P# 7 O MODERN WELDING If"Ya", complete one page for each comparhnat. DATE INSTALLED (YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 6,000 2 ADDITIONAL DESCRIPTION (Fa local a,e only) 438 IL TANK CONTENTS TANK USE 439 PETROLEUM TYPE 448 ® 1. MOTOR VEHICLE FUEL ❑ la. REGULAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL Ofmsrked complete Pchokum Type) ® 1b. PREMIUM UNLEADED ❑ 3. DIESEL ❑ 6. AVIATION FUEL [12. NON -FUEL PETROLEUM ❑ le. MIDGRADE UNLEADED [14. GASOHOL ❑ 99. OTHER [13. CHEMICAL PRODUCT COMMON NAME (from Henrdous Malenels In ant y page) ddl CAS# (from Haaardoa Matenek Inventory page) 442 ❑ 4. HAZARDOUS WASTE (Includes Used OR) ❑ 95. UNKNOWN UL TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL [13. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Checkone item only) EXTERIOR MEMBRANE LINER [195. UNKNOWN ® 2. DOUBLE WALL ❑ 4. SIGNLE WALL IN VAULT ❑ 99. OTHER TANK MATERIAL -pommy tank 191. BARE STEEL 03. FIBERGLASS/ PLASTIC C1 5. CONCRETE ❑95. UNKNOWN 444 (Cheek one item only) 112 STAINLESS STEEL 114 STEEL CLAD W/FIBERGLASS ❑ 8. FRP COMPTIBLE W/I00PA METHANOL ❑ 99. OTHER REINFORCED PLASTIC (FRP) TANK MATERIAL -secondm bak ❑ 1. BARE STEEL ❑ 3. FIBERGLASS/ PLASTIC ❑ 5. CONCRETE ❑ 95. UNKNOWN 445 (Check one item only) ❑ 2. STAINLESS STEEL 194. STEEL CLAD W/FIBERGLASS 138. FRP COMPTIBLE W/100%METHANOL ❑ 99. OTHER REINFORCED PLASTIC (FRP) [110. COATED STEEL ❑ 5. CONCRETE TANK INTERIOR LINING 0 1. RUBBER LINED Ll 3. EPDXY LINING 0 5. GLASS LINING 95. UNKNOWN 446 DATE INSTALLED 447 OR COATING ❑ 2 ALKYD LINING ❑ 4PHENOLIC LINING ®6 UNLINED ❑ 99 OTHER (Checkoneitmnonly) (Forloaluseonly) OTHER CORROSION ❑ 1 MANUFACTURED CATHODIC ❑ 3 FIBERGLASS REINFORCED PLASTIC ❑ 95 UNKNOWN d48 PROTECTION IF APPLICABLE PROTECTION ❑ 41MPRESSED CURRENT ❑ 99 OTHER (Checkone item only) ❑ 2 SACRIFICIAL ANODE (Paloal use only) SPILL AND OVERFILL YEARINSTALLED 450 TYPE(ioal .. may) 451 OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED d53 (Checkellthatapply) ® 1 SPILL CONTAHgMgNT 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 desmipaon ufthe mons om prog,em shoe be submitted to the local agency.) IF SINGLE WALL TANK (check an that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 (Check one Item only) [31 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 ❑ 8 TANK TESTING (SIR) BIENNIAL TANK TESTING ❑ 99 OTHER IV. TANK CLOSURE INFORMATION / PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED (YR/MO/DAY) a55 ESTIMATED DATE LAST USED (YRMODA �57 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIALS 457 gallons ❑ Yes ❑ No UPCF (1/99 revised) Formerly SWRCB Form B