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)�l 1D PROGRAM CONSOLIDATED FO 'of TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 (two pages per tank) 0 TYPE OF ACTION ❑ 1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Check one item 0*) ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWALPERMIT (Specifymmon-forlocaluaeody) (Spm*mason-forlocaluseody) ❑ 8 TANK REMOVED \ 30 BUSINESS NAME(Sece as FACILITY NAME or DBA -Doing Busmem As) 3 FACILITY B): USA GASOLINE #65 LOCATION WITHIN SITE (ophona9 431 1. 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 Ul Yes ❑ No ^ 4 l U0106 MODERN WELDINGP Page P (` If"Yes", com tete one fm rach com mtment. ATE INSTALLED (YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 6,000 2 ADDITIONAL DESCRIPTION (Por Iocduse only) 438 D. TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 IN 1. MOTOR VEHICLE FUEL [Ila. REGULAR UNLEADED 02.LEADED 05. JET FUEL afmmked complete Petroleum Type) ❑ Ib. PREMIUM UNLEADED ®3. DIESEL 06. AVIATION FUEL ❑ 2. NON -FUEL PETROLEUM ❑ Ic. MIDGRADE UNLEADED ❑ 4. GASOHOL ❑ 99. OTHER ❑ 3. CHEMICAL PRODUCT COMMON NAME (from Hac dour Mat nee lnventmy page) 441 CASH (from Ha udow Matends Im Ww page) 442 [14. HAZARDOUS WASTE (Includes Used Oil) ❑ 95. UNKNOWN III. TANK CONSTRUCTION TYPE OF TANK ❑ I. SINGLE WALL ❑ 3. SINGLE WALL WITH [15. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Cheekoneitian.*) EXTERIOR MEMBRANE LINER ❑95. UNKNOWN ® 2. DOUBLE WALL [14. SIGNLE WALL IN VAULT ❑ 99. OTHER TANK MATERIAL -pn umy tad, ® L BARE STEEL ❑ 3. FIBERGLASS / PLASTIC ❑ 5. CONCRETE ❑ 95. UNKNOWN 444 (Checkane item only) ❑ 2. STAINLESS STEEL [14 STEEL CLAD WMIBERGLASS ❑ S. FRP COMPTIBLE W/100% METHANOL ❑ 99. OTHER REINFORCED PLASTIC (FRP) TANK MATERIAL -mcondarymnk ❑ I. BARESTEEL [13. FIBERGLASS/PLASTIC ❑ 5. CONCRETE ❑ 95. UNKNOWN 445 (Check one iten only) ❑ 2. STAINLESS STEEL ® 4. STEEL CLAD W/FIBERGLASS [18. FRP COMPTIBLE W/100%METHANOL ❑ 99. OTHER REINFORCED PLASTIC (FRP) [110, COATED STEEL ❑ 5. CONCRETE TANK INTERIOR LINING D 1. RUBBER LINED 0 3. EPDXY LINING 0 5. GLASS LINING 0 95. UNKNOWN 446 DATE INSTALLED 447 OR COATING ❑ 2 ALKYD LINING ❑ 4 PHENOLIC LINING ®6 UNLINED ❑ 99 OTHER (Checkoneitem only) (Fm lord use only) OTHER CORROSION ❑ 1 MANUFACTURED CATHODIC ❑ 3 FIBERGLASS REINFORCED PLASTIC ❑ 95 UNKNOWN 446 448 PROTECTION IF APPLICABLE PROTECTION ❑ 4IMPRESSED CURRENT ❑ 99 OTHER (Checkmeeem only) ❑ 2 SACRIFICIAL ANODE (For local use only) SPILL AND OVERFILL YEARINSTALLED 450 TYPE Oocal use 0rdy) 451 OVERFILL PROTECTION EQUBMENr:YEAR INSTALLED 452 (Checkdl Bmtapply) ®1 SPILL CONTAINMENT 1997 ®1 ALARM 1997 ❑ 3 PH.L TUBE SHUT OFF VALVE ® 2 DROP TUBE 1997 ® 2 BALL FLOAT 1997 ❑ 4EXEMPT ® 3 STRIKER PLATE 1997 IV. TANK LEAK DETECTION (A description ofthe modta ing program shall besubmittedb the beet agency.) IF SINGLE WALL TANK (check au that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 (Check one iten ody) ❑ 1 VISUAL (EXPOSED PORTION ONLY) ❑ 5 MANUAL TANK GAUGING WG) ❑ I 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 rV. TANK CLOSURE INFORMATION / PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED (YR/MO/DAY) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 gallons ❑ Yes ❑ No UPCF (1/99 revised) Formerly SWRCB Form B