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IFIED PROGRAM CONSOLIDATED FORM /L ri, TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 \NS;"dl � (two pages per tank) ][ Page of_ TYPE OF ACTION y(l NEW SITE PERMIT ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Check one dem only) / ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT (Specify meson-for local use only) (Specify roman-far local use only) ❑ 8 TANK REMOVED 430 BUSINESS NA (same as FAC( NAME arDBA-Doing Basins FACILITY ID: I 3 47 LOCATION WITHIN SITE(0ytiona0 t431 I.TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shall be Sub-' d the local agency.) TA K ID#7,-# /<3� TA K MANUFACTURER 433 COMPARTMENTALIZED TAN Yes ❑ No 434 JIT 'S If"Yes",mmpleomm,page(oreachcornperanent. DATE INSTILLED( EA MO) 435 ANK CAPACITY INGALLON$ �.1 436 NUMBER OF COMPARTMENTS � 437 ADDITIONAL DEZJP TION(For local use amy) Z V 43e 11.TANK CONTENTS k��J///// TANK USE 439 PETROLEUM TYPE 440 1. MOTOR VEHICLE FUEL REGULAR UNLEADED #4. LEADED ❑5. JET FUEL fmwked complete Petmleurn Type) b. PREMIUM UNLEADEDDIESEL ❑6. AVIATION FUEL ❑2. NON-FUEL PETROLEUM ;Kb. MIDGRADE UNLEADED GASOHOL [199.OTHER ❑3. CHEMICAL PRODUCT COMMON NAME (fian Hamolow Materials Inventory page) 441 CAS#(from HamNoa,Materials memory page) 442 ❑4. HAZARDOUS WASTE (lotion.Used Oil) ❑95.UNKNOWN M. TANK CONSTRUCTION TYPE OF TANK 0 1. SINGLE WALL 3. SINGLE WALL WITH LJ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM u3 (Check one item only) EXTERIOR MEMBRANE LINER ❑95. UNKNOWN X2. DOUBLE WALL ❑4. SIGNLE WALL IN VAULT ❑99. OTHER TANK MATERIAL-primary tank EJ 1. BARE STEEL 3. FIBERGLASS/PLASTIC LI 5. CONCRETE 0 95. UNKNOWN 444 (Check one item only) 02. STAINLESS STEEL 94. STEEL CLAD W/FIBERGLASS 08. FRP COMPTIBLE W/100%METHANOL 099.OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-ucondary unk Ej 1. BARE STEEL - FIBERGLASS/PLASTIC 5. CONCRETE 95.UNKNOWN 445 (Ch.kone item only) ❑2. STAINLESS STEEL 4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPTIBLE W/100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10.COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING 0 1.RUBBER LINED 3.EPDXY LINING LJ 5.GLASS LINING 0 95.UNKNOWN 446 DATE INS AALLEDD 447 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING ❑6 UNLINED ❑99 OTHER (Check one item anlY) (For local use only) OTHER CORROSION Cl 1 MANUFACTURED CATHODIC ❑3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN -8 DATE INSTALLED 449 PROTECTION IF APPLICABLE PROTECTION ❑4IMPRESSED CURRENT ❑99 OTHER (Check ane item only) ❑2 SACRIFICIAL ANODE (Far local use only) SPILL AND OVERFIL��LL/ YEAR INSTALLED 450 TYPE(local Uu only) 451 OVERFILL PROTECTION EQNPMENT:YEAR INSTALLED , 452 (Check all that apply) [9.J SPILL CONTAINMENT 0/- 9.1 ALARM I/� K3 FILL TUBE SHUT OFF VALVE ,41 2 DROP TUBE bU 6�2 BALL FLOAAT El EXEMPT Ale STRIKER PLATE � f Al IV.TANK LEAK DETECTION(A d.ctiptian of the monitoring program shall be subrented to the lo.)agency.) IF SINGLE WALL TANK(cheek an that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 (Check one item only) ❑ 1 VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MTG) ,a❑I VISUAL(SINGLE WALL IN VAULT ONLY) LI2 AUTOMATIC TANK GAUGING(ATG) ❑6 VADOSE ZONE D(2 CONTINUOUS INTERSTITIAL MONITORING ❑3 CONTINUOUS ATG ❑7 GROUNDWATER 3 MANUAL MONITORING ❑4 STATISTICAL INVENTORY RECONCILIATION ❑8 TANK TESTING (SIR) BIENNIAL TANK TESTING El 99 OTHER IV.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(12/99 revised) 10 Formerly SWRCB Form B