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IFIED PROGRAM CONSOLIDATED FG..,...i 3 TANKS UNDERGROUND STORAGE TANKS - T AGE 1 5 D3 (two pages per tank) Page?of-i� TYPE OF ACTION ❑1 NEW SITE PERMIT ® 4 AMENDED PERMIT ❑ 5 CHANGE Of INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Check one item only} ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT (Specify reason-for local use only) (Specify reazo -for local use only) ❑ 8 TANK REMOVED 430 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY II): - - - _ - - 1 - - - Van De Pot Enterprises LOCATION WITHIN SITE(Optional) 431 Northwest side of site 1.TANK DESCRIPTION (A scaled plot plan with the location of the UST system inch ding buildings and landmarks shall be submitted to the local agency.) TANK ID# A 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK ❑Yes ® No 434 UNKNOWN TA OR 3:5-a QZ_ UNKNOWN if"Yrs",complete one page for each compartment. DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 1988 ls7mDOv 1 ADDITIONAL DESCRIPTION(For local use only) 433 II.TANK CONTEN S TANK USE 439 PETROLEUM TYPE 440 1. MOTOR VEHICLE FUEL [Ila, REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (Ifmarked complete Petroleum Type) ❑lb. PREMIUM UNLEADED EX3. DIESEL ❑4. AVIATION FUEL ❑2. NON-FUEL PETROLEUM ❑le. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER ❑3. CHEMICAL PRODUCT COMMON NAME (from Hazardous Materials Inventory page) 441 CAS#(from Hazardous Materials Inventory page) 442 ❑4, HAZARDOUS WASTE UNKNOWN (Includes Used Oil) [195.UNKNOWN 111. TANK CONSTRU ION TYPE OF TANK ❑1. SINGLE WALL ❑3. SINGLE WALL WITH ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one item only) EXTERIOR MEMBRANE LINFR ❑95. UNKNOWN El 2. DOUBLE WALL [:14. SIGNLE WALL IN VAULT ❑99. OTHER TANK MATERIAL-primary tank ❑1. BARE STEEL 03. FIBERGLASS/PLASTIC ❑5. CONCRETE ❑95. UNKNOWN 444 (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPTIBLE W/100%METHANOL [199.OTHER REINFORCED PLASTIC FRP TANK MATERIAL-secondary tank ❑ 1. BARE STEEL ®3. FIBERGLASS/PLASTIC ❑S. CONCRETE C195. UNKNOWN 445 (Check one item only) [12. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLA S [38. FRF COMPTIBLE W/100%METHANOL 099-OTHER REINFORCED PLASTIC(FR?) ❑10.COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING ❑ 1.RUBBER LINED ❑3.EPDXY LINING ❑S.GLASS LINING ❑95.UNKNOWN 446 DATE D4STALLED 447 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING ®6 UNLINED ❑99 OTHER (For local use only) (Check one item only) 448 DATE INSTALLED 449 OTHER CORROSION [I1 MANUFACTURED CATHODIC [33 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN PROTECTION IF APPLICABLE PROTECTION ❑4 IMPRESSED CURRENT ❑99 OTHER (Check one item only) ❑2 SACRIFICIAL ANODE {Far local use only) SPILL AND OVERFILL YEAR INSTALLED 450 TYPE(local use only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Check all that apply) ®1 SPILL CONTAINMENT 2003 ® 1 ALARM 2003 Cl 3 FILL TUBE SHUT OFF VALVE ®2 DROP TUBE 2003 ®2 BALL FLOAT 2003 ❑4 EXEMPT ®3 STRIKER PLATE 1988 IV.TANK LEAK DETECTION(A description ofthe menito'g program shall be submitted to the local agency.) IF SINGLE WALL TANK(cheek all that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 (Check one hem only) ❑1 VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(M•TG ❑1 VISUAL(SINGLE WALL IN VAULT ONLY) ❑2 AUTOMATIC TANK GAUGING(ATG) ❑S VADOSE ZONE ®2 CONTINUOUS tNTERSTITIAL MONITORING ❑3 CONTINUOUS ATG ❑7 GROUNDWATER ❑3 MANUAL.MONITORING ❑4 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/MOlDAY} 455 ESTIMATED QUAN'T11TY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 gallon ❑Yes ❑ No UPCF (12/99 revised) t0 Formerly SWRCB Form 3