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IJfflfFIED PROGRAM CONSOLIDATED FORM/ b TANKS \� UNDERGROUND STORAGE TANKS - TANK PAGE 1 (Two pages per tank) Page_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 re von) (Specify revon) ❑ 8.TANK REMOVED BUSINESS NAME(Same as FAcaarY NAME or DBA-Doing Business As) 3. FACILITY m: I. Great American Gas&Car Wash 00/78/9 LOCATION WITHIN SITE minim W) '�`�J`uZ�p�J3 S 431. L TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the localen TANK ID N 032- TANK MANUFACTURER 433, COMPARTMENTALIZED TANK Yes D2 No 434. 1 Containment Solutions V"Yea cumplateone pageforeach comportment. DATE INSTALLED 435. TANK CAPACITY IN GALLONS 036- NUMBER OF COMPARTMENTS 437 (YEAR/MO) 2006/9 20,000 l ADDITIONAL DESCRIPTION(For local use only) - 438. II.TANK CONTENTS TANK USE 439. PETROLEUM TYPE 440. ® 1. MOTOR VEHICLE FUEL ®Ia. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL nfchecked,cmnplae Petroleum Type) ❑Ib. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑to. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME omm Hvarduw Mneriels Imentory,page) 441_ CASH(Bom Hazardous Materials Inventory page) 442. ❑ 4. HAZARDOUS WASTE (Ieeludes Used Oil) ❑ 95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK ❑1. SINGLE WALL [13. SINGLE WALL WITH EXTERIOR ❑5. 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 wik ❑1. BARE STEEL ❑3. FIBERGLASS/PLASTIC ❑5. CONCRETE ❑95.UNKNOWN 444. (Cheek one item only) ❑2. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS ®8. FRP COMPATIBLE ❑99.OTHER: REINFORCED PLASTIC FRP W/100%METHANOL TANK MATERIAL-secondary tank ❑1. BARE STEEL ❑3. FIBERGLASS/PLASTIC 8. FRP COMPTIBLE W/100%METHANOL ❑95.UNKNOWN 4as. (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑9. FRP NON-CORRODABLE JACKET ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING ❑1.RUBBER LINED ❑3.EPDXY LINING 0 5.GLASS LINING ❑95.UNKNOWN 446. DATE INSTALLED 443. OR COATING ❑2.ALKYD LINING [14.PHENOLIC LINING N 6.UNLINED ❑99.OTHER Check one item only) OTHER CORROSION [11.MANUFACTURED CATHODIC ®3.FIBERGLASS REINFORCED PLASTIC ❑95.UNKNOWN 448. DATE INSTALLED "it PROTECTION PROTECTION ❑4.IMPRESSED CURRENT ❑99.OTHER IfApplicable) [12.SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED 450. TYPE 451. OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 452. (Check all that apply) ®1.SPILL CONTAINMENT 2006 ®1.ALARM 2006 [13.FILL TUBE SHUT OFF VALVE ®2.DROP TUBE 2006 ®2.BALL FLOAT 2006 ❑4.EXEMPT ®3.STRIKER PLATE 2006 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) [11. VISUAL(EXPOSED PORTION ONLY) ❑5.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 ❑3.MANUAL MONITORING ❑4. STATISTICAL INVENTORY RECONCILIATION [18.TANK TESTING (SIR)+BIENNIAL TANK TESTING 099. 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 INERT MATERIAL? 457 gallons ❑Yes ❑ No UPCF hwfwrc-b(1/99)-114 http://www.unidoes.org Rev.02/16/00