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UNIFIED PROGRAM CONSOLIDATED FORM l `2Z-��ANKS UNDERGROUND STORAGE TANKS-TANK PAGE 1 ��Ploz (mopagespermnk) TYPE OF ACTION ❑1. NE W SITE PERMIT ❑4. AMENDEDPERMIT ®5. CHANGE OF INFORMATION) [1TEMPORARY6. TEMPORARY SITE CLOSURE Page_of_ (Check one item only) ❑3. RENEWAL PERMIT ❑Z PERMANENTLY CLOSED ON SITE (Specify..-for local we only) (Specify change-for local a only) ❑8. TANKREMOVED 430 BUSINESS NAME(Same az FACILITY NAME ar DBA-Doing Baeisws As) l FACILITY IDN Circle K Stores, Inc. #2705449/05449 LOCATION WITHIN SITE(Optional) 431 G ` I.TANK DESCRIPTION (A scaledplmplan with the location ofthe USTsptem including buildings and landmark shall besubodrued to the local ageny) TANK ID p 432 TANK NUFACTURER 433 COMPARTMENTALIZED TANK ❑ Yet No 434 Q \I C C IfUYesU,complete one page for each cons rtment. DATE INSTALLED(YEAR/MO) 435 TANK APACITY IN GALLONS 436 NUMBER O@ COMPARTMENTS 437 ((��II``//��]] I ADDITIONAL DESCRIPTION(For local use only) 438 11.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 1. MOTORVEHICLEFUELa REGULAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL (lfmarked.complete Petroleum Type) ❑Ib. PREMIUM UNLEADED ❑ 3. DIESEL ❑ 6. AVIATIONFUEL ❑ 2. NON-FUEL PETROLEUM ❑11. MIDGRADE UNLEADED ❑ 4. GASOHOL El 3. CHEMICAL PRODUCE ❑99. OTHER ❑ Hazallow Materink Inventory page) 442 4. HAZARDOUS WASTE Unclad. COMMON NAME(from Hazardous Materials lnvenrory page) 441 CAS k U m Used Oil) ❑95 XERXES 111.TANK CONSTRUCTION TYPE OF TANK ❑1 SINGLE WALL ❑ 3, SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one item only) DOUBLE WALL EXTERIOR MEMBRANE LINER ❑95. XERXES ❑ 4. SINGLE WALL INA VAULT [199 OTHER TANK MATERIAL-primacy tank ❑1. BARE STEEL FIBERGLASS I PLASTIC ❑5. CONCRETE ❑95. XERXES 444 (Chcknneiremanly) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑g, PRP COMPATIBLE W/100%METHANOL ❑99 OTHER REINFORCED PLASTIC FRP TANK MATERIAL-socandary tank ❑1 BARE STEEL FIBERGLASS/PLASTIC ❑8. PRP COMPATIBLE W/I W%METHANOL ❑95. XERXES 445 (Chuck one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑9. FRP NON-CORRODIBLE JACKET ❑99. OTHER REINFORCED PLASTIC(FRP) [110. COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING ❑ I. RUBBER LINED ❑3. EPDXY LINING OR COATING ❑2 ALKYD LINING ❑5. GLASS LINING ❑95. XERXES 446 DATE MSTALLED 447 ❑4. PHENOLIC LINING UNLINED ❑99. OTHER Check ane item on! Fos local we onl OTHER CORROSION ❑1 MANUFACTURED FMERGLASS REINFORCED PLASTIC 095. XERXES 448 DATE INSTALLED 449 PROTECTION IF APPLICABLE CATHODIC [34, IMPRESSED CURRENT ❑99. OTHER PROTECTION (Checkoneitemanly) 02. SACRIFICIAL ANODE (Far local we only) SPI LL AND OVERFI LL YEAR INSTALLED 450 TYPE(Forlacalweonly) 451 OVERFILLPROTECTIONEQUIPMEW,: ARMSTALLED 452 (Check all thm app/y/ SPILL CONTAINMENT +.J ❑1. ALARM 'W FILL TUBE SHUT OFF VALVE Pq1 DROPTUBE ❑2. BALL FLOAT ❑4. EXEMPT 3. STRIKER PLATE IV. TANK LEAK DETECTION (A description ofthe monitaringpmgmm shall besubodued to the local agency.) IF SINGLE WALL TANK(Chock all that apply): 411IFDOUBLE WALLTANK ORTANK WITH BLADDER(Checkone item only) 454 ❑I, VISUAL(EXPOSED PORTION ONLY) EIS, MANUAL TANK GAUGING(MTG) ❑1. VISUAL(SINGLE WALL M VAULT ONLY) ❑2. AUTOMATIC TANK GAUGING(ATG) [16. VADOSE ZONE CONTINUOUS INTERSTITIAL MONITORING ❑ N 3. CONTUOUSATG [-17. GROUNDWATER ❑3. MANUAL MONITORING ❑4. STATISTICAL INVENTORY RECONCILIATION(SIR) ❑8. TANK TESTING BIENNIA.TANK TESTING ❑W. OTHER V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH MERT MATERIAL? 457 gallons ❑Yon ❑No UPCF(1/99 revised) Formerly SWRCB Form