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fln=D PROGRAM CONSOLIDATED FO vi TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 (two pages per tank) Page of TYPE OF ACTION ❑ 1 NEW SITE PERMIT C14 AMENDED PERMIT 5 CHANGE OF O TION C16 TEMPORARY SITE CLOSURE 1 ((heck me tem only) ❑ 7 PERMANENTLY CLOSED ON SITE ^^ ❑ 3 RENEWAL PERMIT (Specify reason-for local use ooy) (Specify reason-for tical use only) ❑ 8 TANK REMOVED O 3 Y I BUSINESS me as FACfll7Y �pA ma en>mess A.) FACILITY[D: Q ? 3 LOCATION WITHIN SITE(optional) y �. � 7 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# '� J2 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK Y No 434 elmSUI •\`�. if"yes".eompiete me page for"eh compsnmcot. DATE 9JSTALLIJD(YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 L9 el CfJI ADDITIONAL DESCRIPTION(For local uae only) 43s II.TANK CONTENTS A,TK ii .SE 431 PL t ROL '�1 T11 '3 C OTORHICLEFUELIa. REGU[.4R UNLEADED ❑2. LEADED ❑5. JET FUEL (Ud coeglee pesrulaam Type) b. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION FUEL ❑2. NON-FUEL PETROLEUM ❑ Ic. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER ❑3. CHEMICAL PRODUCT COMMON NAME (from Hu rdous Materials tavcntory page) 441 CAS#(from Hazardous Materials Inventory page) 442 ❑4. HAZARDOUS WASTE. (Includes Used oil) ❑95.UNKNOWN M. TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL ❑3. SINGLE WALL WITH ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check-ft-only) EXTERIOR MEMBRANE LINER ❑95. UNKNOWN 2. DOUBLE WALL ❑4. IGNLE WALL IN VAULT ❑99. OTHER TANK MATERIAL-pnmary tank Cr 1. BARE STEEL P0, FIBERGLASS/PLASTIC rl 5. CONCRETE ❑95. UNKNOWN 444 (Cbeck one nem only) ❑2. STAINLESS STEE e ❑4. EL CLAD W/FIBERGLASS ❑8. FRP COMPTIBLE W/100%METHANOL [199.OTHER INFORCED PLASTIC(FRP) TANK MATERIAL-secondary unk El I. BARE STEEL . FIBERGLASS/PLASTIC 5. CONCRETE ❑95. UNKNOWN 445 (Check one acm only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS [18. FRP COMPTIBLE W/100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) ❑ 10.COATED STEEL Cl 5. CONCRETE TANK INTERIOR LINING ❑ 1.RUBBER LINED ❑3.EPDXY LINING5 GLASS LINING 95.UNKNOWN 446 DATE INSTALLED 447 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING UNLINED ❑99 OTHER (Check one aem only) (For tical use only) OTHER CORROSION ❑ 1 MANUFACTURED CATHODIC 3 FIBERGLASS REINFORCED PLASTIC C]95 UNKINTONIIN 448 DATE INSTALLED 441 PROTECTION IF APPLICABLE PROTECTION ❑4IMPRESSED CURRENT ❑99 OTHER (Check ane nem only) C12 SACRIFICIAL ANODE (For lout use only) SPILL AND OVER LL YEAR INSTALLED 450 TYPE(io i use only) 451 OVERFILL PROTECTION EQUIIPMMEENT:YEAR INSTALLED 452 (Check 4 tha t aPP1Y) Jr,SPILL CONTAINMENT ❑ I ALARM �Q3 FILL TUBE SHUT OFF VALVE 2 DROP TUBE ❑'_ BALL FLOAT �❑�EXEMPT 3 STRIKER PLATE IV.TANK LEAK DETECTION(A desrnpoon of the monaor g pmgnm shall be mbmated to the local agency.) IF SINGLE WALL TANK(Cbeckalltbat.pply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 (Check one item only) ❑ I VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MTG) XO VISUAL(SINGLE WALL IN VAULT ONLY) Cl2 AUTOMATIC TANK GAUGING(ATG) C16 VADOSE ZONE CONTINUOUS INTERSTITIAL MONITORING C13 CONTINUOUS ATG ❑7 GROUNDWATER 3 MANUAL MONITORING ❑4 STATISTICAL INVENTORY RECONCILIATION ❑8 TANK TESTING (SIR) BIENNIAL TANK TESTING [_1 99 OTHER IV.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE LLED WITH INERT MATERIAL? 457 ESTIMATED DATE LAST USED(YR/MO/DAY) 455 [ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FI gallons E]Yes E] No UPCF(12/99 revised) 10 Formerly SWRCB Form B