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Y <br /> UNIFIED PROGRAM CONSOLIDATED FORM nol f Q uF f TANKS <br /> UNDERGROUND STORAGE TANKS-TANK <br /> 6!/ (rw Paga ver mnk) <br /> Page_of <br /> TYPE OF ACTION [11 NEW SITE PERMIT ❑4. AMENDED PERMIT ®5. CHANGE OF INFORMATION) ❑6. TEMPORARY SITE CLOSURE <br /> ❑7. PERMANENTLY CLOSED ON SITE <br /> (Check one at.only) 430 <br /> ❑3. RENEWALPERMIT 8. TANK REMOVED <br /> (Spmifyrem0n-f0,bahlase0nly) (Specify change-far lanl use only) <br /> I <br /> BUSINESS NAME(Same a FACILITY NAME or DHA-Doing Business All 3 FACILITY ID# <br /> Circle K Stores, Inc.#2705449/05449 <br /> 431 <br /> LOCATION WITHIN SITE(0priman) <br /> I.TANK DESCRIPTION (A scaled plot plan with rhe laati0n of the UST rynrm including bu(I ap and landmarb shall be svbmi.eAmthe Taal agenry) <br /> 432 TANK PACCURER 433 COMPARTMENTALIZED TANK ❑ Yes No 434 <br /> TANK ID p fNy If LIYesO,wonplet one page far each co artment. <br /> 436 NUMBER OF COMPARTMENTS 431 <br /> DATE INSTAL E (Y(YEAR/MO) 435 TANK CAPACITY M GA CONS <br /> 1 00� <br /> ADDITIONAL D SCRIPTION(FOrloca/useon/y) 438 <br /> II.TANK CONTENTS <br /> 4ao <br /> TANK USE 439 PETROLEUM TYPE 3. JET FUEL <br /> 1. MOTORVEHICLEFURL ❑la REGULAR UNLEADED ❑ 2. LEADED ❑ 6. AVIATION FUEL <br /> (if ked,..Plate Petroleum type) )J jE. PREMIUMUNLEADED ❑ 3. DIESEL ❑99. OTHER <br /> ❑ 2.NON-FUEL PETROLEUM ❑Ic. MIDGRADEUNLEADED ❑ 4. GASOHOL ❑ <br /> ❑3 CHEMICAL PRODUCT441 CAS#(from Hazardous Mazeri.ls/+m 11-1ti ge) 442 <br /> ❑ 4 HAZARDOUS WASTE(Includes COMMON NAME(T m Nnzardous Materials/nvenrorypage) <br /> usaOiI) <br /> ❑95. XERXES <br /> ILL TANK CONSTRUCTION <br /> TYPE OF TANK F11. SINGLE WALL ❑ 3. SINGLEWALLWITH ❑❑95. SINGLE <br /> INGL WALL WITH INTERNAL BLADDER SYSTEM 443 <br /> ME <br /> �lif 2. DOUBLE WALL EXTERIORMBRANELINER <br /> (Check one item only) �\ ❑ 4. SINGLE WALL IN A VAULT ❑99. OTHER <br /> TANK MATERIAL-primary taM ❑1. BARE STEEL 3. FIBERGLASS/PLASTIC ❑5. CONCRETE ❑95. XERXES 444 <br /> ❑2. STAINLESS STEEL 4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE W/I OW.METHANOL ❑99. OTHER <br /> (Chackoneilemarb,) . REINFORCEDPLASTIC FRP <br /> TANK MATERIAL-sx9ndary tank ❑1. BARE STEEL �3 FIBERGLASS/PLASTIC ❑8. ERP COMPATIBLE W/I00%METHANOL ❑95. XERKES 445 <br /> (Check one irem only) ❑2. STAINLESS STEEL ❑4_ STEELREINFC UPLASTIC(FRP) ❑IO.FRY COA]ED STEEL JACKET ❑99. OTHER <br /> ❑5. CONCRETE <br /> TANKINTERIORLINING ❑ I. RUBBERLINED ❑3. EPDXY LINING ' ❑1�5k. GLASS LPING ❑9S XERXES 446 <br /> DATE INSTALLED 447 <br /> OR COATING ❑2 ALRYD LINUJG ❑4. PHENOLIC LINING . UNLINED ❑99. OTHER <br /> For 101.1 use onf <br /> Check one irem onl DATE INSTALLED 449 <br /> OTHER CORROSION ❑1. MANUFACTURED FIBERGLASS REINFORCED PLASTIC ❑95. XERXEB 448 <br /> PROTECTION IF APPLICABLE CATHODIC ❑4. IMPRESSED CURRENT 099. OTHER <br /> PROTECTION (For laal use only) <br /> tWSOGLEW�LT�K(Ch�kall,h.t�ppt,)- <br /> ❑2. SACRIFICIAL ANODE <br /> 452 <br /> ILL YEAR INSTALLED 450 TYPE(For local use only) 451 OVERFILL PROTECTION EQUIPMENT.YEAR INSTALLED 1 <br /> SPILL CONTAINMENT ❑1 ALARM `syr;;f3. FILLTUBESHUTOFFVALVE ! <br /> ) DROP TUBE ❑2. BALL FLOAT t14_ EXEMPT <br /> STRIKER PLATE fqK <br /> IV. TANK LEAK DETECTION (A description of the monUoring pregmm shall besubmiaed to the lomlagenry.) <br /> EWALLTANK(Chaka/hhatappty): 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER(Check are item only) 454 <br /> ❑ <br /> 5. MANUAL TANK GAUGING(MTG) [:]I. VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑1, VISUAL(EXPOSEDPORTION ONLY) CONTINUOUS QYfERSTITIAL MONITORING <br /> ❑2. AUTOMATICTANK GAUGING(ATGROUNDWATER ❑3. MANUAL MONITORING <br /> ❑3. CONTINUOUSAM ❑7. GROUNDWATER <br /> ❑4. STATISTICALINVENTORY RECONCILIATION(SIR)+ ❑❑899 TOA�RSTING <br /> BIENNIAL TANK TESTING <br /> V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YR/MOMAY) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLEDEl WITH <br /> INER❑No MATERIAL, 457 <br /> ¢e lou <br /> UPCF(1/99 revised) Formerly SWRCB Form B <br />