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UNIFIED PROGRAM CONSOLIDATED FORM 0I UJ.NG TANKS CA,Tl UNDERGROUND STORAGE TANKS - TANK PAGE 1 (Two pages per tank) Page_6_of_7_ TYPE OF ACTION ® 1.NEW PERMIT [14.AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION [16.TEMPORARY TANK CLOSURE 4M (Chink one item only) ❑ 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE (Specify«ason) (Spacify reacn) ❑ S.TANK REMOVED BUSINESS NAME(Some w FACILITY NAME or DBA-Doing Business M) 3, FACILITY ID: 1. RALEY'S FUEL STATION#356 LOCATION WCfHIN SITE(Optana0 431, I.TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the IocaLagone TANK ID# 432. TANK MANUFACTURER 433. COMPARTMENTALIZED TANK ®Yes No 034. 2B XERXES If"Ya;'complete one page for each compartment DATE INSTALLED 435, TANK CAPACITY IN GALLONS 436, NUMBER OF COMPARTMENTS 437 (YEAR/MO) /L 2006/02 2-00-7101 10,000 ADDITIONAL DESCRIPTION(For Imal ase only) 438. II.TANK CONTENTS TANK USE 439. PETROLEUM TYPE 440. ® 1. MOTOR VEHICLE FUEL ❑Ia. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (Ifcheckd,complete Petroleum Type) ❑Ib. PREMIUM UNLEADED ®3. DIESEL ❑6. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑to. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: ❑ 3. CHEMICAL.PRODUCT COMMONNAME (from Barardous Materials lnvmtmypege) �1' CAS#(from Fivardoua Macnals Inventory,page) 44x. ❑ 4. HAZARDOUS WASTE AUTO DIESEL 68476-34-6 (Includes Used Oil) ❑ 95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK ❑1. SINGLE WALL ❑3. SINGLE WALL WITH EXTERIOR ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. (Check one item only) MEMBRANE LINER ❑95. UNKNOWN 02 DOUBLE WALL El 4. SINGLE WALL IN A VAULT ❑99. OTHER TANK hIATERIAL-prhtwy tank ElL. BARE STEEL Zi 3. FIBERGLASS/PLASTIC ❑5. CONCRETE El 95.UNKNOWN 044. (Chink one item only) ❑2. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE [:199.OTHER: REINFORCED PLASTIC W/100%METHANOL TANK MATERIAL-secondary tank ❑1. BARE STEEL ®3. FIBERGLASS/PLASTIC ❑8. FRP COMPTIBLE W/100%METHANOL ❑95.UNKNOWN 445. (Check one item only) ❑2. STAINLESS STEEL [14. STEEL CLAD W/FMERGLASS [19. FRP NON-CORRODABLE JACKET [199.OTHER REINFORCED PLASTIC(FRP) [110. COATED STEEL [15. CONCRETE TANK INTERIOR LINING ❑1.RUBBER LINED ❑3.EPDXY LINING [15.GLASS LINING [195.UNKNOWN 446. DATE INSTALLED "T OR COATING ❑2.ALKYD LINING ❑4.PHENOLIC LINING ®6.UNLINED ❑99.OTHER Check one item anl OTHER CORROSION ❑1.MANUFACTURED CATHODIC ®3.FIBERGLASS REINFORCED PLASTIC ❑95.UNKNOWN 44s. DATE INSTALLED 409. PROTECTION PROTECTION ❑4.IMPRESSED CURRENT ❑99.OTHER f A hcable ❑2.SACRIFICIAL ANODE SPILL AND OVERFILL YE INSTALLED Oso, TYPE 451. OVERFILL PROTECTI EQUIPMENT: YEAR INSTALLED 45x. (Check all that apply) ®1.SPILL CONTAINMENT 2 6 PHI,TITE ®1.ALARM 2 N ❑3.FILL TUBE SHUT OFF VALVE ®2.DROP TUBE 2 6- PHIL TITE ®2.BALL FLOAT b [14.EXEMPT 0 3.STRIKER PLATE 2P26 PHIL TITE P✓.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 ❑7.GROUNDWATER [13.MANUAL MONITORING ❑4. STATISTICAL INVENTORY RECONCILIATION [18.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 456TANK FILLED WITH INERT MATERIA.? 451. gallons ❑Yes ❑ No UPCF hwfwre-b(1/99)-1/4 http:/Iwww.unidocs.org Rev.02/16/00