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: .4EMD PROGRAM CONSOLIDATED FC;'. `r -05 L/ TANKS UNDERGROUND STORAGE T -- TANK E 1 (two pages per tan] k) or TYPE OF ACTION ❑I NEW SITE PERMIT M 4 AMENDED PERMIT ❑ 5 CHANGE O INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Check one item only) ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT (Specify reason--for local use only) (Specify reaso -for local use only) ❑ STANK REMOVED 430 BUSINESS NAME(Sazne as FACILITY NAME or DBA--Doing Business As) Van De Pol Enterprises LOCATION WITHIN SITE(Optional) 431 Northwest side of site I.TANK DESCRIPTION (A scaled plot plan with the location of the UST system incl ding buildings and landmarks shall be submitted to the local agency.) TANK ID# 1 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK ❑Yes ® No 434 UNKNOWN /s V3 -5 2 el UINKNOWN If"Yes",complete one page for each compartment. DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 436,- NUMBER OF COMPARTMENTS 437 1988 Lal oCO 1 ADDITIONAL DESCRIPTION(For local use only) 438 II.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 3_4. MOTOR VEHICLE FUEL ❑ la. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (If marked complete Petroleum Type) ❑lb. PREMIUM UNLEADED U4. DIESEL [ 6. AVIATION FUEL ❑2. NON-FUEL PETROLEUM ❑Ic. MIDGRADE UNLEADED [14. GASOHOL ❑99.OTHER ❑3. CHEMICAL PRODUCT COMMON NAME (From Hasardom Materials Inventory page) 441 CAS#(from Hazardous Materials Inventory page) 44'- [14. HAZARDOUS WASTE UNKNOWN (Includes Used oil) ❑95.UNKNOWN II1. TANK CONSTRUCTION TYPE OF TANK ❑I. SINGLE WALL ❑3. SINGLE WALL WITH ❑5. SINGLE WALT.WITH INTERNAL BLADDER SYSTEM 443 (Check one item only) EX'T'ERIOR MEMBRANE LINE P ❑95. UNKNOWN ®2. DOUBLE WALL ❑4. SIGNLE WALL IN VAULT ❑99. OTHER TANK MATERIAL-primary tank ❑ 1. BARE STEEL 03. FIBERGLASS/PLASTIC ❑S. CONCRETE ❑95. UNKNOWN 444 (Check one item only) [32. SrAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLAS ❑6. FRP COMPTIBLE Wil 00%METHANOL ❑99.OTHER REINFORCED PLASTIC FRP TANK MATERIAL-secondary tank [13. BARE STEEL ®3. FIBERGLASS I PLASTIC ❑5. CONCRETE ❑95. UNKNOWN 445 (Check one item only) Cl 2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGL SS C:18. FRP COMPTIBLE W/100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FBP) ❑10.COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING ❑I.RUBBER LINED ❑3.EPDXY LINING ❑5.GLASS LINING Cl 95.UNKNOWN 446 DATE INSTALLED 447 OR COATING ❑2 ALKYD LINING [1 4 PHENOLIC LINING ®6 UNLINED ❑99 OTHER (For local use only) (Check one item only) 449 DATE INSTALLED 449 OTHER CORROSION ❑ I MANUFACTURED CATHODIC ❑3 FIBERGLASS REINFORCED 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) ast OVERFILL PROTECTION EQU[PMENT:YEAR INSTALLED 452 (Check all that apply) ® 1 SPILL CONTAINMENT 2003 ® 1 ALARM 2003 ❑3 FILL TUBE SHUT OFF VALVE 212 DROP TUBE 2003 ®2 BALL FLOAT 2003 ❑4 EXEMPT ®3 STRIKER PLATE 1988 IV.TANK LEAK DETECTION(A description of the monit ring program shall be submitted to the local agency.) IF SINGLE WALL TANK(Check all that apply) 453 IF DOUB LE WALL TANK OR TANK WITH BLADDER 454 (Check one item only) ❑I VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MT(:) ❑ 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 I.V.TANK CLOSURE INFORMATION/PERI HENT CLOSURE 1N PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 455 ESTIMATED QUANTITY OF SUBST NCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 gallon ❑Yes ❑ No UPCF(12199 revised) 10 Formerly SWRCB Farm B