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r1 a IED PROGRAM CONSOLIDATED F TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 (two pages per tank) Page -of TYPE OF ACTION ❑ 1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Check one item only) ❑ 7 PERMANENTLY CLOSED ON SrrE ❑ 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)3 FACILITY ID: t LOCATION WITHIN SITE (Optionat) 431 I. 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 4;4 If "Yes", complete one page for each compartment. DATE INSTALLED (YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 ADDITIONAL DESCRIPTION (For local use only) 438 II. TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 ❑ 1. MOTOR VEHICLE FUEL ❑ la. REGULAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL (If marked complete Petroleum Type) ❑ lb. PREMIUM UNLEADED ❑ 3. DIESEL [16. AVIATION FUEL [12. NON -FUEL PETROLEUM ❑ Ic. MIDGRADE UNLEADED ❑ 4. GASOHOL ❑ 99. OTHER ❑ 3. CHEMICAL PRODUCT COMMON NAME (fan, Hazardous Materials Inventory page) 441 CAS# (from Hazardous Materials Inventory page) 442 ❑ 4. HAZARDOUS WASTE (Includes Used Oil) ❑ 95. UNKNOWN III. TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL [13. 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 - primary tank ❑ 1. BARE STEEL ❑ 3. FIBERGLASS / PLASTIC 5. CONCRETE ❑ 95. UNKNOWN 444 (Check one item only) ❑ 2. STAINLESS STEEL [:14. 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 [15. CONCRETE 95. UNKNOWN 445 (Check one item only) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD W/FIBERGLASS [38. 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 LINING ❑ 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) OTHER CORROSION ❑ 1 MANUFACTURED CATHODIC ❑ 3 FIBERGLASS REINFORCED PLASTIC ❑ 95 UNKNOWN 448 448 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 ❑ 1 ALARM ❑ 3 FILL TUBE SHUT OFF VALVE ❑ 2 DROP TUBE ❑ 2 BALL FLOAT ❑ 4 EXEMPT ❑ 3 STRIKER PLATE IV. TANK LEAK DETECTION (A description of the monitoring program shall be submitted to the local agency.) IF SINGLE WALL TANK (Cheek all 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) ❑ 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 INFORMATION / PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED (YR/MO/DAY) 455 456 ESTIMATED QUANTITY OF SUBSTANCE REMAININGANK T FILLED WITH INERT MATERIAL? 457 gallons ❑ Yes ❑ No UPCF (1/99 revised) 173 Formerly SWRCB Form B