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r-1 - - - "AFIED PROGRAM CONSOLIDATED FQ TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 (two pages per tank) Page _ of TYPE OF ACTION ❑ 1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT �K5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Check one item only) , ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT (Specify reason - for kx:al use only) (Specify 4m - for local use only) ❑ 8 TANK REMOVED 430 BUSINESS NAME (Satre as FACBITY NAME or DBA - Doing Business As) FACILITY ID: 1 -f- 5 G a- + GV- o v e r .5 3 LOCATION WITHIN SITE (optionao 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 ❑ No 434 ` t,l p d e- Y' ^yL W .Q /,r If "Yes", complete one page for each compartment DATE INSTALLED (YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 O 000 /A/M/(M �w O ADDITIONAL DESCRIPTION (For keel use only) 438 rasT-e1 �L II. TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 . MOTOR VEHICLE FUEL *&Ia. REGULAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL (If marked complete Petroleum Type) Xb. PREMIUM UNLEADED [13. DIESEL ❑ 6. AVIATION FUEL [12. NON -FUEL PETROLEUM ❑ lc. MIDGRADE UNLEADED [14. GASOHOL ❑ 99. OTHER [13. CHEMICAL PRODUCT COMMON NAME (from Hazardous Materials Inventory page) 441 CAS# (from Hazardous Materials Invemory page) 442 ❑ 4. HAZARDOUS WASTE (Includes Used Oil) S O / / j e- ❑ 95. UNKNOWN III. TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL [33. SINGLE W ALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one item only) EXTERIOR MEMBRANE LINER ❑ 95. UNKNOWN X2. DOUBLE WALL ❑ 4. SIGNLE WALL IN VAULT ❑ 99. OTHER TANK MATERIAL - primer' tank ❑ 1. BARE STEEL ❑ 3. FIBERGLASS/ PLASTIC ❑ 5. CONCRETE ❑ 95. UNKNOWN 444 (Check one item only) ❑ 2. STAINLESS STEEL �Z 4. STEEL CLAD W/FIBERGLASS E38. FRP COMPTIBLE W/100% METHANOL ❑ 99. OTHER C ` REINFORCED PLASTIC (FRP) TANK MATERIAL - secondary talc ❑ I. BARE STEEL ❑ 3. FIBERGLASS / PLASTIC ❑ 5. CONCRETE ❑ 95. UNKNOWN 4t5 (Check one item only) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD W/FIBERGLASS ❑ 8. FRP COMPTIBLE W/100% METHANOL ❑ 99- OTHER REINFORCED PLASTIC (FRP) [110. COATED STEEL ❑ 5. CONCRETE TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING [195. UNKNOWN 446 DATE INSTALLED A47 OR COATING ❑ 2 ALKYD LINING ❑ 4 PHENOLIC LINING Q2r'1; UNLJNED ❑ 99 OTHER (For local use only) (Check one item only) q4S OTHER CORROSION ❑ 1 MANUFACTURED CATHODIC X3 FIBERGLASS REINFORCED PLASTIC [395 UNKNOWN PROTECTION IF APPLICABLE PROTECTION ❑ 4 IMPRESSED CURRENT ❑ 99 OTHER (Check one item only) . [32 SACRIFICIAL ANODE (For local use only) SPILL AND OVERM-L YEAR INSTALLED 450 TYPE (local use only) 451 OVERFILL PROTECTION EQUIPMENTNEAR INSTALLED 452 (Check all that apply) �1` SPILL CONTAINMENT ❑ 1 ALARM FILL TUBE SHUT OFF VALVE .92 DROP TUBE ❑ 2 BALL FLOAT ❑ 4 EXEw r R3 STRIKER PLATE _._. IV. TANK LEAK DETECTION (A description of the monitoring program shall be submitted to the local agency.) IF SINGLE WALL TANK (check all that appy) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 � (Check one item only) ❑ I VISUAL (EXPOSED PORTION ONLY) ❑ 5 MANUAL TANK GAUGING (MTG) ❑ 1 VISUAL (SINGLE WALL IN VAULT ONLY) I ❑ 2 A11-1 OMATIC TANK GAUGING (ATG) ❑ 6 VADOSE ZONE )RO CONTINUOUS INTF..RSTTxTAL MONITORING X3 CONTINUOUS ATG ❑ 7 GROUNDWATER ❑ 3 MANUAL. MONITORING ❑ t STATISTICAL INVENTORY RECONCILIATION ❑ 8 TANK TESTING (SIR) BIENNIAL TANK TESTING ❑ 99 OTHER _ _ IV. TANK CLOSURE INFORMATION / PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED (YR/MO/DAY) 455 ESTATED QUANTITY OF SUBSTANCE REMAINING 456 IM TANK FILLED WITH INERT MATERIAL? 457 gallons ❑ Yes ❑ No UPCF (1/99 revised) 173 Formerly SWRCB Form B