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TKnIED PROGRAM CONSOLIDATED FO TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 (two pages per tank) Page_oC TYPE OF ACTION ❑ 1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT la 5 CHANGE OF F RMATION ❑ 6 TEMPORARY SITE CLOSURE (Check one tem only) U_Pfla& ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT (Spedfy mson-for kwl use ooy) (Specify mwo-for tical use only) ❑ 8 TANK REMOVED BUSINESS NAME(Same a.FACQ.RY NAME or DBA-Doing Busmen As) FACILITY[D: Z1 Z 3 LOCATION WITHIN SITE(optional) 31 L TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the I agency.) I TANK ID It / p2 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK ❑Yes o 434 5.0 tf'Yes".complete one page for each compartn�t. cy- DATE INST LED AR/MO) 473 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 ADDITIONAL DES ON(For local use only) 438 II.TANK CONTENTS IN TALK uSE ?Lf CLCL?t TY 440 Xml-'rised MOTOR VEHICLE FUEL REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL wtuN]ae Peonleum Type) ❑ Ib. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION FUEL ❑2. NON-FUEL PETROLEUM ❑ Ic. 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 (Incudes Used Oil) ❑95.UNKNOWN III. TANK CONSTRUCTION TYPE OF TANK Cl1. SINGLE WALL ❑3. SINGLE WALL WITH ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Chick one aero only) EXTERIOR MEMBRANE LINER Cl 95. UNKNOWN 2. DOUBLE WALL ❑4 SIGNLE WALLIN VAULT ❑99. OTHER TANK MATERIAL-primary tind ON4APESTEEL FIBERGLASS/PLASTIC T CONCRETE ❑95. UNKNOWN 444 (Check one san only) [12. STAINLESS STEEL C]4. STEEL CLAD W/FIBERGLASS [IS. FRP COMPTIBLE W/100%METHANOL El 99.OTHER i REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary tank 1. BARE STEEL IBERGLASS/PLASTIC ❑5. CONCRETE ❑95. UNKNOWN 445 (Chock one sem only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/F(BERGLASS [18. FRP COMPTIBLE W/100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) ❑ 10.COATED STEEL ❑S. CONCRETE 4. TANK INTERIOR LINING ❑ 1.RUBBER LINED ❑3.EPDXY LINING ❑5.GLASS LINING 95.UNKNOWN 446 DATE INSTALLED 447 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING LINED ❑99 OTHER (Check one aero only) (For local use only) OTHER CORROSION ❑ 1 MANUFACTURED CATHODIC FIBERGLASS REINFORCED PLASTIC [:195 UNKNO�'.�1 44s DATE INSTALLED 449 PROTECTION IF APPLICABLE PROTECTION ❑4 1 SED CURRENT ❑99 OTHER (Check one item only) ❑2 SACRIFICIAL ANODE (For loci]use only) SPILL AND OVER 1£LLQ., YEAR INSTALLED 450 TYPE(local use only) 451 OVERFILL PROTECTION UIPMENT:YEAR INSTALLED 452 (Check.0 that■pply) I SPILL CONTAINMENT ❑ I ALARM 3 FILL TUBE SHUT OFF VALVE DROP TUBE ❑2 BALL FLOAT XEMPT 3 STRIKER PLATE IV.TANK LEAK DETECTION(A desmpt-of the monitoring program shall be submitted to the tical agency.) IF SINGLE WALL TANK(Cbeck.0 that.ppy) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 (Check out sem 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 ONTINUOUS INTERSTITIAL MONITORING ❑3 CONTINUOUS ATG ❑7 GROUNDWATER t10 NANUAL 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/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