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0NOIED PROGRAM CONSOLIDATED FORlOI TANKS \0� 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 nem only) ❑ 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE (specify reason) (Specify reawn) ❑ 8.TANK REMOVED BUSINESS NAME(Sameas FACUTY NAME or nen-notal,Business As) 3. FACILITY m: L Great American Gas&Car Wash �'g�9 p LOCATION WITHIN SITE(optional) SO�'3 431. I.TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local enc .) TANK ID k 2 432 TANK MANUFACTURER 433. COMPARTMENTALIZED TANK ®Yes No 434. 2B Containment Solutions If-Yes,"complete onepMe for cachcompartment. DATE MS ALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS 437 (YEAR/MO) 2006/9 10,000 2 ADDITIONAL DESCRIPTION(For local.only) 438. II.TANK CONTENTS TANK USE 619- PETROLEUM TYPE 440. ® 1. MOTOR VEHICLE FUEL ❑Ia. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL Ofchecked.complete Petroleum Type) ❑Ib. PREMIUM UNLEADED ®3. DIESEL El 6. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑In. MIDGRADE UNLEADED ❑4. GASOHOL [199.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME (from Haaardous bfaterials Imemay page) 441. CAS#(from Hazardous Mazerials Inventory page) 442 ❑ 4. HAZARDOUS WASTE (Inoludea Used Oil) ❑ 95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK ❑1. SINGLE WALL 03, SINGLE WALL WITH EXTERIOR ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 441 (Check one item only) MEMBRANE LIFTER ❑95. UNKNOWN ®2. DOUBLE WALL [14, SINGLE WALL IN A VAULT ❑99. OTHER TANK MATERIAL-primary tank ❑ L BARE STEEL ❑3. FIBERGLASS/PLASTIC ❑5. CONCRETE 0 95.UNKNOWN 444. (Check one ism only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ®8. FRP COMPATIBLE ❑99.OTHER: REINFORCED PLASTIC W/100%METHANOL TANK MATERIAL-secondary tank ❑1. BARE STEEL [13. FIBERGLASS/PLASTIC 19 8. FRP COMPTIBLE W/100%METHANOL ❑95.UNKNOWN 445. (Check one item only) ❑2. STAINLESS STEEL [14. 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 [13 EPDXY LINING ❑5.GLASS LINING ❑95.UNKNOWN 446. DATE INSTALLED 447. OR COATING ❑2.ALKYD LINING ❑4.PHENOLIC LINING N 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 ❑4.IMPRESSED CURRENT ❑99.OTHER If A &able ❑2.SACRIFICIAL ANODE SPILL AND OVERFILL YEARINSTALLED 450. TYPE 451. OVERFILL PROTECTION EQUIPMENT: YEARINSTALLED 452. (Check all that apply) ® 1.SPILL CONTAINMENT 2006 ®L ALARM 2006 ❑3.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) ❑1. 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 [13. CONTINUOUS ATG ❑7.GROUNDWATER ❑3.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(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.unid"s.org Rev.02/16/00