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U PERGROUND STORAGE TA114RS TANK PAGE 1 UNIFIED PROGRAM CONSOLIDATED FORM FFRESNOUNTY HUMAN SERVICES SYSTEM-DEPARTMENT OF COMMUNITY HEALTH-ENVIRONMENTAL HEALTH SYSTEM 1221 Fulton Mall, Post Office Box 11867, Fresno, California 93775 (559)445-3271 (Iwo ages perfank) Page of _ TYPE OF ACTION ❑1.NEW SITE PERMIT Cl 4. AMENDED PERMIT ❑ 5. CHANGE OF INFORMATION) El❑ 8 7. TEMPORARY SITE CLOSED CLOSURE SITE (Check one item only) ❑3.RENEWAL PERMIT LY B. TANK REMOVED 430 (Specify reason-for local use only) (Specify change-lorlocal use aniy) BUSINESS NAME(Same at FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID It - 1 4 � jy I :../A' � �Q, ' • L�M CO f i!- 431 LOCATION WITHIN SITE(Optional) I.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER t 433 COMPARTMENTALIZED TANK ❑ Yes ❑ No 434 JK'j C5 ] If"Yes.complete one page for each compartment. DATE INSTALLED(YEARIMO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 jib I +��'f.,�,Liu�•_., '� 438 ADDITIONAL DESCRIPTION(Far local use only) ll.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 MOTOR VEHICLE FUEL [Ila. REGULAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL (if marked,complete Petroleum Type) ❑lb. PREMIUM UNLEADED ❑ 3. DIESEL ❑ AVIATION FUEL/ - ` ❑ 2. NON-FUEL PETROLEUM ❑1c. MIDGRADE UNLEADED ❑ 4. GASOHOL L"199. OTHER 'L.�I,A) L`) ❑ 3. CHEMICAL PRODUCT COMMON NAME(from Hazardous Materials lnvenfory pegs) 441 CAS*f(rom Hazardous Materials Inventory page) 442 ❑ 4. HAZARDOUS WASTE(lnGudes Used Oil) ❑95. UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK - 1. SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one item only) ❑ 2. DOUBLE WALL EXTERIOR MEMBRANE LINER Q 95. UNKNOWN ❑ 4. SINGLE WALL IN A VAULT Q 99- OTHER TANK MATERIAL-primary tank 1. BARE STEEL ❑ 3. FIBERGLASS I PLASTIC ❑ 5. CONCRETE ❑95. UNKNOWN 444 (Check ane item only) ❑ 2. STAINLESS STEEL ❑4. STEEL CLAD WIFIBERGLASS ❑ 8. FRP COMPATIBLE W1100%METHANOL ❑99. OTHER REINFORCED PLASTIC FRP TANK MATERIAL-secondary tank Q 1 BARE STEEL ❑ 3. FIBERGLASS I PLASTIC ❑ 8. FRP COMPATIBLE WJIW%METHANOL ❑95. UNKNOWN 445 (Check one item only) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD WIFIBERGLASS ❑ '9. FRP NON-CORRODIBLE JACKET ❑99. OTHER REINFORCED PLASTIC(FRP) [:110 COATED STEEL ❑ S. CONCRETE TANK INTERIOR LININGDATE INSTALLED 447 ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING ❑95. UNKNOWN 446 OR COATING Q 2. ALKYD LINING ❑ 4. PHENOLIC LINING Ei'<UNLINED ❑99. OTHER local use Check one item only) OTHER CORROSION Q MANUFACTURED CATHODIC C] 3. FIBERGLASS REINFORCED PLASTIC 95. UNKNOWN 448 DATE INSTALLED 449 PROTECTION IF APPLICABLE PROTECTION ❑ 4. IMPRESSED CURRENT ❑99. OTHER (Check one item only) ❑ 2. SACRIFICIAL ANODE (For local use only) SPILL AND OVERFILL YEAR INSTALLED 450 TYPE(Forlocaf use only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED I 452 1 (Check all that apply) ❑ 1. SPILL CONTAINMENT ❑ 1. ALARM ` ❑ 3. FILL TUBE SHUT OFF VALVE ❑ 2. DROP TUBE ❑ 2. BALL FLOAT ❑ 4. EXEMPT ❑ 3. STRIKER PLATE - -- �_- �- - IV. TANK LEAK DETECTION IF SINGLE WALL TANK(Check all that apply): 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER(Check one item only): 454 ❑ 1, 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. GROUNCWATER ❑ 3. MANUAL MONITORING ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR)+ ❑ S. TANK TESTING BIENNIAL TANK TESTING ❑99- OTHER V.TANK CLOSURE INFORMATION 1 PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YRIt�OIDAY) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 gallons 11 Yes L+'SNo HSS-1017 UPCF(4199) F:ICUPAIF0RMSIUSTFRM02.WPT Formerly SWRCB Form B