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lED PROGRAM CONSOLIDATED FO , TANKS UNDERGROUND STORAGE T S - T AGE 1 61(,10 (two pages per tank) Page�(, of_LL TYPE OF ACTION ❑1 NEW SITE PERMIT ® 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Chock one item only) ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT (specify reason-for local use only) (Specify reason for local use only) ❑ 8 TANK REMOVED 430 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) FACILITY ID: I 3 Van De Pol Enterprises LOCATION WITHIN SITE(Optional) 431 Northwest side of site L 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 UNKNOWN NOuTN LTN"OWN If"Yes",complete one page for each compartment. DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 1988 0,001 ADDITIONAL DESCRIPTION(For local use only) 438 Il.TANK CONTENT TANK USE 439 PETROLEUM'TYPE 440 al. MOTOR VEHICLE FUEL ❑Ia. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (If marked complete Petroleum Type) QLlb. PREMIUM UNLEADED [13. DIESEL ❑6. AVIATION FUEL ❑2. NON-FUEL PETROLEUM [Ile. MIDGRADE UNLEADED [14. GASOHOL ❑99.OTHER [13. CHEMICAL PRODUCT COMMON NAME (from Hazardous Materials Inventory page) 441 CAS#(from Hazardous Materials Inventory page) _ 442 ❑4. HAZARDOUS WASTE UNKNOWN (Includes Used Oil) ❑95.UNKNOWN III. TANK CONSTRU ION TYPE OF TANK ❑1. SINGLE WALL ❑3. SINGLE WALL WITH ❑S. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one item only) EXTERIOR MEMBRANE LINER ❑95. UNKNOWN 10 2. DOUBLE WALL ❑4. SIGNLE WALL IN VAULT ❑99. OTHER TANK MATERIAL-primary tank ❑ 1. BARE STEEL E 3. FIBERGLASS/PLASTIC ❑5. CONCRETE ❑95. UNKNOWN 444 (Check one item only) ❑2. STAINLESS STEEL [14. STEEL CLAD WIFIBERGLASS [18. FRP COMPTIBLE W/100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL.-secondary tank ❑ 1. BARE STEEL E 3. FIBERGLASS/PLASTIC ❑5. CONCRETE [195. UNKNOWN 445 (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 IN NG ❑95,UNKNOWN 446 DATE INSTALLED 447 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING ®6 UNLINED ❑99 OTHER (Check one item only) (For local use only) 448 DATE INSTALLED 449 OTHER CORROSION ❑1 MANUFACTURED CATHODIC ❑3 FIBERGLASS REINFORCE PLASTIC ❑95 UNKNOWN PROTECTION IF APPLICABLE PROTECTION ❑4 IMPRESSED CURRENT ❑99 OTHER (Check one item only) ❑2 SACRIFICIAL ANODE (For 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 ❑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 monitoring program shall be submitted to the local agency.) IF SINGLE WALL TANK(Checkall that apply) 453 IF DOUBLE WALL TANKORTANK WITH BLADDER 454 (Check one item only) ❑1 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 ❑8 TANK TESTING (SIR) BIENNIAL TANK TESTING ❑99 OTHER IV.TANK CLOSURE INFORNIATION/PERMi VENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 gallons ❑Yes ❑ No UPCF(12/99 revised) 10 Formerly SWRCB Form B