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MIF IED PROGRAM CONSOLIDATED FOI. i • TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 (two pages per tank) Page TYPE OF ACTION ❑1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT 4 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE 0 7 PERMANENTLY CLOSED ON SITE (Check nee am only) ❑ } RENEWAL PERMIT (Specify mann_for kwl use only) (Specify msoa-for but use only) ❑ 8 TANK REMOVED azo FACILITY ID: l BUSINESS N Same■s FACM TY NAME or DBA-Doing Buamea As) a LOCATION WITHIN SITE(optional) 170 L TANK DESCREMON (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 ' .wx e S If"Yes".complete one page for each comp■rtwmt. J DATE INSTAL ED( o JAR/MO) 1431 TANK CAPACITY IN GALL1 S 436 NUMBER OF COMP CR)MENTS 437 7 Z� c d 0,961 ADDITIONAL DESCRIPTION(For Loin use only) 438 U.TANK CONTENTS TANK USE 439• PETROLEUM ROLE;'UM TY7E 44" I. MOTOR VEHICLE FUEL REGULAR UNLEADED [12. LEADED ❑5. JET FUEL (If marked eotuplete Petro"m Type) ❑ Ib. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION FUEL ❑2. NON-FUEL PETROLEUM Cl 1c. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER ❑3. CHEMICAL PRODUCT COMMON NAME t6om Navrdous Muerials Inventory page) 441 CASA(from Ila>Jrdous Matc is In tory page) 412 ❑4. HAZARDOUS WASTE (Inckdes Used Oil) ❑95,UNKNOWN M. TANK CONSTRUCTION TYPE OF TANK ❑ I. SINGLE WALL ❑3. SINGLE WALL WITH ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one item only) EXTERIOR MEMBRANE LINER ❑95. UNKNOWN �<2_ DOUBLE WALL ❑4. SIGNLE WALL IN VAULT ❑99. OTHER TANK MATERIAL-prmvry'ank 1. BARE STEEL 3. FIBERGLASS/PLASTIC 5. CONCRETE ❑95. UNKNOWN 444 (Check one kern only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPTIBLE W/100%METHANOL. ❑99.OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary tank 1. BARE STEEL 3. FIBERGLASS/PLASTIC D 5. CONCRETE ❑95. UNKNOWN 445 (Check one item only) ❑2. STAINLESS STEEL ❑ . STEEL CLAD WNIBERGLASS ❑8. FRP COMPTIBLE W/100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10.COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING Cl 1.RUBBER LINED ❑3.EPDXY LINING �❑5.GLASS LINING Ej 95.UNKNOWN 446 DATE INSTALLED 447 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING py6UJaLINED ❑99 OTHER (Check one ilem only) !� (For Local uu only) OTHER CORROSION ElI MANUFACTURED CATHODIC RGLASS REINFORCED PLASTIC C395 UN .TI 448 DATE INSTALLED 449 PROTECTION IF APPLICABLE PROTECTION ❑4 IMPRESSED CURRENT ❑99 OTHER (Check one item only) ❑2 SACRIFICIAL ANODE (For Local use only) SPILL ANDOVE ILL YEAR INSTALLED 450 TYPE(local 451 OVERFILL PROTECTIONE kPMENT:YEARINSTALLED 45: (Chekall that apply) 1SPILL CONTAINMENT I ALARM FILL TUBE SHUT OFF VALVE 2 DROP TUBE ❑2 BALL FLOAT EXEMPT 3 STRIKER PLATE IV.TANK LEAD DETECTION(A deu tion of the mooaorutg program shall be wbmitted to the local agency.) IF SINGLE WALL TANK(Check dl that apply) 453 IF DOUBLE WALL TANK OR TANK 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) Cl 6 VADOSE ZONE2 CONTINUOUS INTERSTITIAL MONITORING El CONTINUOUS ATG ❑7 GROUNDWATER ❑3 NUAL 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? i57 gallons ❑ Yes ❑ No UPCF(12/99 revised) 10 Formerly SWRCB Form B