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4. -,j iiMD PROGRAM CONSOLIDATED FG,r+i' TANKS UNDERGROUND STORAGE TANKS - TANK AGE 1 �C �p (two pages per tank) Page Z of j TYPE OF ACTION ❑I 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 rca5 a-for local use only) ❑ 8 TANK REMOVED. 430 BUSINESS NAME(Same as FACILrfY NAME or DSA-Doing Business As) FACILITY ID: Van De Pol Ente rises ail LOCATION WITHIN SITE(optional) Northwest side of site I.TANK DESCRIPTION (A scaled plot plan with the location of the UST system incl uding buildings and landmarks shall be submitted to the local agency.) TANK ID# , 1'1i�NO 4432/ �T7Aw7NvK�MT ANUFACTURER 433 COMPARTMENTALIZED TANK El Yes ® No 434 UNKNOWN TA V 7 UNKNOWN if"Yes'.complete one page for each compartment. DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 1988 t0,0C.0 1 ADDITIONAL DESCRIPTION(For local use only) 438 II.TANK CONTE TS TANK USE 439 PETROLEUM TYPE 440 �L 1. MOTOR VEHICLE FUEL Cl la. REGULAR UNLEADED [:12. LEADED ❑5. JET FUEL (If marked complete Petroleum Type) ❑ Ib. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION FUEL ❑2. NON-FUEL PETROLEUM ❑ Ic. MIDGRADE UNLEADED ❑4. GASOHOL N.99.OTHER [13. CHEMICAL PRODUCT COMMON NAME (from Hazardous Materials Inventory page) 441 CAS#(from Hazardous Materials Inventory page) 442 ©4. HAZARDOUS WASTE RtiL+"j F-vd i UNKNOWN (Includes Used oil) ❑95.UNKNOWN III. TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL [13. SINGLE WALL WITH 115, SINGLE WALL WITH INTERNAL BLADDER SYSTEYI 443 (Check one item only) EXTERIOR MEMBRANE LINER ❑95. UNKNOWN ®2. DOUBLE WALL ❑4. SIONLE WALL IN VAULT ❑99. OTHER TPNK MATERIAL-primary tank ❑1. BARE STEEL 03. FIBERGLASS!PLASTIC ❑5. CONCRETE ❑95. UNKNOWN 444 (Check one item only) ❑2. STAINLESS STEEL [14. STEEL CLAD WIFIBERGLASS ❑8. FRP COMPTIBLE WI100%METHANOL [199.OTHER REINFORCED PLASTICFRP TANK MATERIAL-secondary tank C11. BARE STEEL 03. FIBERGLASS l PLASTIC ❑5. CONCRETE ❑95. UN MOWN 445 (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD WIFIBERGL SS (:18. FRP COMPTIBLE WI100%METHANOL Cl 99.OTHER REINFORCED PLASTIC(FILP) ❑ 10.COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING ❑ 1.RUBBER LINED ❑3.EPDXY LINING ❑5.GLA3S LINING ❑95.UNKNOWN 446 DATE INSTALLED 447 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING ®6 UNLII ED ❑99 OTHER (For local use only) (Check one item only) 448 DATE INSTALLED 449 OTHER CORROSION [II MANUFACTURED CATHODIC ❑3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN PROTECTION IF APPLICABLE PROTECTION ❑4 IMPRESSED CURRENT ❑99 OTHER (Check one item only) El SACRIFICIAL ANODE (For kcal use only} SPILL AND OVERFILL YEAR INSTALLED 450 TYPE(local use only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Check all 0-apply) ®1 SPILL CONTAINMENT 2003 ®1 ALARM 2003 ❑3 FILL TUBE SHUT OFF VALVE ®2 DROP TUBE 2003 212 BALL FLOAT 2003 0 4 EXEMPT ®3 STRIKER PLATE 1988 I.V.TAINK LEAK DETECTION(A description of the monis ring program shall be submitted to the local agency.) IF SINGLE WALL TANK(Chock all that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 (Check one item only) ❑ I VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MTG) ❑ I 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 0.8 TANK TESTING (SIR) BIENNIAL TANK TESTING ❑99 OTHER IV.TANK CLOSURE INFORMATION/PE ANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR(MO1DAY) 455 ESTIMATED QUANTITY OF SUBST NCE REMAINING 456TANK FILLED WITH INERT MATERIAL? 457 gallo s El Yes ❑ No UPCF(12199 revised) 10 Formerly SWRCB Form 13