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NIFIEO PROGRAM CONSOLIDATED FO <br /> � <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 TANKS <br /> (Mb pages per tank) <br /> Page _ W <br /> TYPE OF ACTION ❑I.NEW SITE PERMIT ❑ 4. AMENDED PERMIT ❑ 5. CHANGE OF INFORMATION) ❑ 6. TEMPORARY SITE CLOSURE <br /> (Check ons item only) <br /> ❑ T. PERMANENTLY CLOSED ON SITE <br /> ❑3.RENEWAL PERMIT (Specify mason-rorlwel use only) (Spray charge-fnrlocal use onto <br /> 8. TANK REMOVED 430 <br /> BUSINESS NAME(Sema as FACILITY NAME of DEA-Dnog Business Aa) FACILITY ID a 1 <br /> LeZDIS 0 2 <br /> LOCATION WITHIN SITE(Optional 431 <br /> g I R W ose ' aff- P(v <br /> 1.TANK DESCRIPTION <br /> TANK ID# TANK MANUFACTURER COMPARTMENTALIZED TANK ❑ Yes ❑ No <br /> 6/5Z um r, If'Yes'.wmplele one Page br eacn wmpanoanL <br /> DATE INSTALLED(YEARIMO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> )1,30 5 o b <br /> ADDITIONAL DESCRIPTION(Forlowl use onW <br /> II.TANK CONTENTS <br /> TANK USE 432 PETROLEUM TYPE <br /> ❑ 1. MOTOR VEHICLE FUEL ❑1a. REGULAR UNLEADED ❑ 1 LEADED ❑ 5. JET FUEL <br /> Orm oloXf.compbfe Patmkum Type) 0 th. PREMIUM UNLEADED ❑ 3. DIESEL ❑ S. AVIATION FUEL <br /> {��.`qq�� <br /> ❑ 2. NON-FUEL PETROLEUM ❑1c. MIDGRADE UNLEADED ❑ 4. GASOHOL W. OTHER *Bf*bN <br /> ❑ 3. CHEMICALPRODUCT <br /> ❑ T HAZARDOUS WASTE(/otludes COMMON NAME(M1om Hezallous Mafenala lnvemmrypage) CAS#(lmm Hazardova Mefenels lnuentorypage) <br /> Use"O# <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK 1. SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> (Qhe4#one#em Pny) ❑ 2. DOUBLEWALL EXTERIOR MEMBRANE LINER 00UNKNOWN <br /> ❑ 4. SINGLE WALL IN A VAULT 0% OTHER <br /> TANK MATERIAL.pnmaly lank 1 BARE STEEL ❑ 3. 1eERG1,kSSIP1_ASTC ❑ 5. CONCRETE ❑95. UNKNOWN <br /> (Check one item onty) ❑ 1 STAINLESS STEEL ❑4. STEEL CUD W)FIBERGLASS ❑ 8. FRPCOMPATISLEW/1005METHANOL 099. OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-sewn"ery lank Q 1, BARE STEEL ❑ 1 FIBERGLASS/PLASTIC ❑ 8. FRP COMPATIBLE W/1W%METHANOL 095. UNKNOWN <br /> (Check one item onty) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD W/FIBERGLASS ❑ 9. FRP NONCORROOIBLE JACKET ❑99. OTHER <br /> REINFORCED PLASTIC(FRP) 1310. COATED STEEL <br /> ❑ S. CONCRETE <br /> TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ S. GLASS UNING,-)c M. UNKNOWN433 DATEINSTALLEO <br /> OR COATING <br /> CMck one item only) 0 2. ALKYD LINING ❑ 4. PHENOLIC LINING ❑ 5. UNLINED ❑99. OTHER <br /> Forlwal uss ) <br /> OTHER LION IF CORROSION ❑ 1. MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC 95. UNKNOWN 434 <br /> CDATEINSTALLED <br /> OTHER ORROPPLICABLE PROTECTION <br /> ❑ 4. IMPRESSED CURRENT W. OTHER <br /> (Checkmle#emonly) ❑ 2. SACRIFICIAL ANODE (For/ocaluss orgy) <br /> SPILL AND OVERFILL YEARINSTALLED TYPE(Fo,M luso only) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (C5ack all that apply) 0 1 SPILL CONTAINMENT <br /> ❑ 1.ALARM ❑ 3. FILL TUBE SHUT OFF VALVE <br /> ❑ 2. DROP TUBE ❑ i BALL FLOAT ❑ 4. EXEMPT <br /> ❑ 3. STRIKER PLATE <br /> IV. TANK LEAK DETECTION <br /> IF SINGLE WALL TANK(Check a4 tMf epplY). IF DOUBLE WALL TANK OR TANK WITH BLADDER(Check one ibm onyl: <br /> ❑ 1. VISUAL(EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING(MTG) ❑ 1. VISOAL(SINGLEWALL IN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ S. VADOSEZONE ❑ Z CONTINUOUSINTERSTLPALMONITORING <br /> ❑ 3. CONTINUOUSATG ❑ T. GROUNDWATER ❑ 3. MANUALMONITORING <br /> ❑ 4. STATISTICAL INVENTORY RECONCILIATION ISIR)+ ❑ S. TANKTESTING <br /> BIENNIAL TANK TESTING <br /> ❑N. OTHER <br /> V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YRIAIOIDAY) ESTIMATED QUANTITY OOyFF�SUBSTANCE REMAINING 0.15 TANK FILLED VATH INERT MATERIAL? <br /> 11 galPono Yea <br /> ❑N <br /> CUPAFORNI(4199) • • Formerly SWRCS Fong B <br />