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enuD PROGRAM CONSOLIDATED A TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 (Two pages per tank) Page 1 of TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 4.AMENDED PERMIT ® 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430. (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE (Specify...) (Specifyroason) ❑ S.TANK REMOVED BUSINESS NAME(Sam,u FACILITY NAME or DBA-Doing Bminen As) 3. FACILITY ID: I ARCO FacilityNo.9600 LOCATION WITHIN SITE(optional) 431. I.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 ❑Yes ® No 434, 3 Modern Welding If"Yos;'complete one page for each compartment. DATE INSTALLED 435. TANK CAPACITY IN GALLONS 436, NUMBER OF COMPARTMENTS (YEAR/MG) 43]. 04/15/95 12093 0 ADDITIONAL DESCRIPTION(For local use only) 438. II.TANK CONTENTS TANK USE 439. PETROLEUM TYPE 440. ® 1. MOTOR VEHICLE FUEL ®la. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (ifchecked,complete Pmtelemn Type) ❑Ib. PREMIUM UNLEADED El 3. DIESEL ❑6. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑le. MmGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME (Item Haamdoae materials Invemory page) 441' CAS#(from Fla ardous MaterialsInventorypage) 442. ❑ 4. HAZARDOUS WASTE Gasoline 8006-61-9 (includes Used Oil) ❑ 95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK ❑1. SINGLE WALL [13, SINGLE WALL WITH EXTERIOR [15. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. (Check one item only) MEMBRANE LINER ❑95. UNKNOWN ®2. DOUBLE WALL [14. SINGLE WALL IN A VAULT ❑99. OTHER TANK MATERIAL-primary tank ❑1. BARE STEEL ❑3. FIBERGLASS/PLASTIC ❑5. CONCRETE ❑95.UNKNOWN 444. (Check onto mannerly) ❑2. STAINLESS STEEL 04. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE ❑99.OTHER: REINFORCED PLASTICW/100%METHANOL TANK MATERIAL-secondary tank ❑1. BARE STEEL LJ 3. FIBERGLASS/PLASTIC 08. FRP COMPIIBLE W1100%METHANOL El 95.UNKNOWN 445. (Check one item only) ❑2. STAINLESS STEEL ®4. STEEL CLAD W/FIBERGLASS [19. FRP NON-CORRODABLE JACKET [199.OTHER REINFORCED PLASTIC(FRP) [110. COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING ❑1.RUBBER LINED ❑3.EPDXY LINING ❑5.GLASS LINING ❑95.UNKNOWN 446, DATE INSTALLED 447 OR COATING [12.ALKYD LINING ❑4.PHENOLIC LINING ®6.UNLINED ❑99.OTHER Check one item only) OTHER CORROSION ❑1.MANUFACTURED CATHODIC ®3.FIBERGLASS REINFORCED PLASTIC ❑95.UNKNOWN 448. DATE INSTALLED 449. PROTECTION PROTECTION [14.IMPRESSED CURRENT ❑99.OTHER (If Applicable) ❑2.SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED 450. TYPE 451. OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 452. (Check all that apply) ®1.SPILL CONTAINMENT 1995 ❑1.ALARM unit ®3.FILL TUBE SHUT OFF VALVE ®2.DROP TUBE 1995 ®2.BALL FLOAT talc. [14.EXEMPT ®3.STRIKER PLATE 1995 IV.TANK LEAK DETECTION (A description of the monitoring program shall be submitted to the local agency.) IF SINGLE WALL TANK 453, IF DOUBLE WALL TANK OR TANK WITH BLADDER 454. (Check all that apply) (Check one item only) ❑1.VISUAL(EXPOSED PORTION ONLY) [15.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 [17.GROUNDWATER [13.MANUAL MONITORING ❑4. STATISTICAL INVENTORY RECONCILIATION ❑8.TANK TESTING (SIR)+BIENNIAL TANK TESTING ❑99.OTHER V.TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(yRjMO/DAY) 455' ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456, TANK FILLED WITH INERT MATERIAL? 457' gallons ❑Yes ❑ No �ir�d'r�v+a1v,7 UPCF hwfwrc-b(1/9/9)-2/4 http://www.unidocs.org D c Rev.02/16/00