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UNIFIED PROGRAM CONSOLIDATED FORP � � ro3 TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 (Two pages per tank) Page 1 of 2 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 reason) (Spalfyreaon) ® 8.TANK REMOVED BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business Aa) 3, FACILITY ID: 1' 90 MOUNT OSO STREET BENJAMIN PROPERTY 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 Z No 434, sf'Tes,"complete one page L:each compartment. DATE INSTALLED 435. TANK CAPACITY IN GALLONS 436- NUMBER OF COMPARTMENTS 0,37. (YEAR/MO) 350 ONE ADDITIONAL DESCRIPTION(For local use only) 432. IL TANK CONTENTS TANK USE 439, PETROLEUM TYPE 4410, ❑ 1. MOTOR VEHICLE FUEL ❑ la. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (Ifchecked,complete Petmleum Type) ❑ Ib. PREMIUM UNLEADED 03. DIESEL El 6. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑ to. MIDGRADE UNLEADED [14. GASOHOL ®99.OTHER: ❑ 3. CHEMICAL PRODUCT COMMONNAME (&om Haasrdousalaterialslnventorypage) 441CAS#(6mm Hazardous Matenals Inventory page) 44' ❑ 4. HAZARDOUS WASTE (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 ❑2. DOUBLE WALL ❑4. SINGLE WALL IN A VAULT [199. OTHER TANK MATERIAL-primerytank ®1. BARE STEEL El 3. FIBERGLASS/PLASTIC ❑5. CONCRETE ❑95.UNKNOWN 444. (Chink one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE ❑99.OTHER: REINFORCED PLASTIC RP W/100%METHANOL TANK MATERIAL-secondary tank ❑1. BARE STEEL [13. FIBERGLASS/PLASTIC ❑8. FRP COMPTIBLE W/100%METHANOL ❑95.UNKNOWN 445. (Check one item only) ❑2. STAINLESS STEEL [14. STEEL CLAD W/FBERGLASS ❑9. FRP NON-CORRODABLE JACKET [199.OTHER REINFORCED PLASTIC(FRP) ❑ 10. COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING ❑ 1.RUBBER LINED ❑3.EPDXY LINING ❑5.GLASS LINING ❑95.UNKNOWN 40,6, DATE INSTALLED 447. OR COATING ❑2.ALKYD LINING ❑4.PHENOLIC LINING 0 6.UNLINED ❑99.OTHER_ Check one item only) OTHER CORROSION ❑ L MANUFACTURED CATHODIC [13.FIBERGLASS REINFORCED PLASTIC ®95.UNKNOWN 448. DATE INSTALLED 449. PROTECTION PROTECTION ❑4.IMPRESSED CURRENT [199.OTHER (If Applicable) [12.SACRIFICIAL ANODE SPILL AND OVERFILL YEARINSTALLED 450. TYPE 451, OVERFILL PROTECTION EQUIPMENT: YEARINSTALLED 452. (Check all that apply) ❑ 1.SPILL CONTAINMENT ❑1.ALARM [13.FILL TUBE SHUT OFF VALVE [12.DROP TUBE ❑2.BALL FLOAT ❑4.EXEMPT ❑3.STRIKER PLATE 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 ❑3, CONTINUOUS ATG ❑7.GROUNDWATER ❑3.MANUAL MONITORING ❑4. STATISTICAL INVENTORY RECONCILIATION ❑8.TANK TESTING (SIR)+BIENNIAL TANK TESTING El 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' UNKNOWN NONE gallons ❑Yes ® No UPCF hwfwre-b(1/99)-1/4 http://www.unidocs.org Rev.02/16/00