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&D PROGRAM CONSOLIDATED F00 e�\ !S �3 TANKS UNDERGROUND STORAGE TANKS - TANK PAGf��3s�o`� (Two pages per tank) Page_of TYPE OF ACTION ❑ L NEW PERMIT ❑ 4.AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430. (Check one dem only) ❑ 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE (Specify reazon) (Specifyneamn) ® S.TANK REMOVED BUSINESS NAME(Same a;FACILITY NAME or DBA-Doing Batman M) 3, FACILITY BENNY PROPERTY LOCATION WTTHIN SITE(optional) LEFT SOUTHWEST CORNER NEAR SIDEWALK 431 I.TANK DESCRIPTION (Ascaled plot plan witli the location of the UST system including buildings and landmarks shall be submitted to the local agency.). TANK ID# 43a31 TANK MANUFACTURER 433. COMPARTMENTALIZED TANK ❑Yes ® No 4u, UST-1 .515 709 5 UNKNOWN If'yrR"complete one page for each compartment. DATE INSTALLED 435. TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS (YEAR/MO) 437. UNKNOWN -500 ONE ADDITIONAL DESCRIPTION(For local cane only) 43g IL TANK CONTENTS TANK USE 439. PETROLEUM 7"YPE 440. Cl1. MOTOR VEHICLE FUEL 11 In. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (Ifehecke4 complete Petmlwm Type) ❑Ib. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑Ic. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME (Both Hazardous Materials inventory page) 061 CAS#(from Haaardoua Materials lawmory page) 442. Cl 4. HAZARDOUS WASTE (Includes Used Oil) ® 95.UNKNOWN ITL TANK CONSTRUCTION TYPE OF TANK ®1. SINGLE WALL ❑3. SINGLE WALL WITH EXTERIOR ❑5. SINGLE WALL WITH INTERNAL BLADDER SYS'rFM 443. (Check one item only) MEMBRANE LINER ❑95. UNKNOWN ❑2. DOUBLE W ALL 14.. SINGLE WALL IN A VAULT ❑99. OTHER TANK MATERIAL-primary tank ®1. BA R E ST EEL ❑3FIBERGLASS/PLASTIC 05. CONCRETE 1195.UNKNOWN 444. (Chink one item only) 02. STAINLESS STEEL 04. STEEL CLAD W/FIBERGLASS [IS. FRP COMPATIBLE ❑99.OTHER: REINFORCED PLASTICW/100%METHANOL ry TANK MATERIAL-secondatank ❑l. BARE STEEL ❑3. FIBERGLASS/PLASTIC ❑8. FRP COMPTIBLE W1100%METHANOL ❑95.UNKNOWN 445. (Check are item only) [12. STAINLESS STEEL❑4. STEEL CLAD W/FIBERGLASS ❑9. FRP NON-CORRODABLE JACKET ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL ❑5. CONCRETE INTERIOR TERIOR LINING ❑1.RUBBER LINED ❑3.EPDXY LINING ❑5.GLASS LINING ®95.UNKNOWN 446. DATE INSTALLED 447. OR COATING ❑2.ALKYD LINING [14.PHENOLIC LINING ❑6.UNLINED ❑99.OTHER Check ow item only OTHER CORROSION 0 1.MANUFACTURED CATHODIC ❑3.FIBERGLASS REINFORCED PLASTIC ®95.UNKNOWN Ne, DATE INSTALLED 449. PROTECTION PROTECTION [14.IMPRESSED CURRENT 1199.OTHER (If Applicable) ❑2.SACRIFICIAL ANODE SPILL AND OVERFILL YEARINSTALLED 450. TYPE 451. OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 452. (Check all that apply) ❑I.SPILL CONTAINMENT ❑t.ALARM ❑3.FILL TUBE SHUT OFF VALVE El 2.DROP TUBE ❑ El J.STRIKER PLATE 2.BALL FLOAT El4.EXEMPT IV.TANK LEAK DETEC'T'ION (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) El 1. VISUAL(EXPOSED PORTION ONLY) ❑5.MANUAL TANK GAUGING(MTG) ❑ 1.VISUAL(SINGLE WALL IN VAULT ONLY) [12. AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE [12.CONTINUOUS INTERSTITIAL MONITORING [13.CONTINUOUS ATG ❑7.GROUNDWATER ❑3.MANUAL MONITORING ❑4. STATISTICAL INVENTORY RECONCILIATION ❑8.TANK TESTING (SIR)+BIENNIAL TANK TESTING 1199. 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 ) �7Ie EMPTY gallons ❑Yes ® No UPCF hwfwrc-b(1/99)-1/4 http://www.unidocs.org Rev.02/16/00