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RW <br /> NIFIED PROGRAM CONSOLIDATED FO <br /> TANKS <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 1 <br /> (two pages per nk) <br /> 1. <br /> Pale f <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT C3 +4. AMENDED PERMIT ®�5. CHANGE OF I FOR TION) C1 8. TEMPORARY SITE CIOSu RE <br /> (Check*no item only) ^� ❑ 7. PERMANENTLY CLOSED ON S <br /> •, r <br /> ❑7.RENEWAL PERMIT (Specify reason-for local use only) (S change•for local use only) ❑ S. TANK REMOVED 430 <br /> BUSINES E(Same as FACILITY NAME or DBA,Doln9 Business As) FACILITY IDN 1 <br /> LOCATION WITHIN_§jTE_qtionaq 43 <br /> 1.TANK TANK DESCRIPTION <br /> TANK ID N TANK MANUFACTURER COMPARTMENTALIZED TANK ❑ Yes ❑ No <br /> `-� If'Yes',complete one page for each compartment. <br /> DATE I S ALLED(YEAR/MO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> ADDITIONAL DESCRIPTION(Forlocal use only) <br /> 11.TANK CONTENTS <br /> TANK USE 432 PETROLEUM TYPE <br /> ❑ 1. MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL <br /> (If marked,complete Petroleum Type) ❑lb. PREMIUM UNLEADED ❑ 3. DIESEL ❑ 6. AVIATION FUEL <br /> ❑ 2. NON-FUEL PETROLEUM ❑tc. MIOGRADE UNLEAOED ❑ 4. GASOHOL ❑99. OTHER <br /> ❑ 3. CHEMICAL PRODUCT CAS N(from Hazardous Materials inventory page) <br /> ❑ 4. HAZARDOUS WASTE(Includes COMMON NAME(hom Hazardous Materials Inventory page) <br /> Used OiQ <br /> 0 95 UNKNOWN <br /> Ill.TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1. SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> (Check one item only) ❑ 2. DOUBLE WALL EXTERIOR MEMBRANE LINER ❑95. UNKNOWN <br /> ❑ 4. SINGLE WALL IN A VAULT ❑99. OTHER <br /> TANK MATERIAL.primary tank ❑ 1 BARE STEEL ❑ 3. FIBERGLASS I PLASTIC ❑ 5. CONCRETE ❑95. UNKNOWN <br /> (Check one r(em only) ❑ 2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑ 8. FRP COMPATIBLE W/100%METHANOL ❑99. OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL•secondary tank ❑ 1 BARE STEEL ❑ 3. FIBERGLASS I PLASTIC ❑ 8. FRP COMPATIBLE W/100%METHANOL ❑95. UNKNOWN <br /> (Check one item only) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CUD W/FIBERGLASS ❑ 9. FRP NON-CORRODIBLE JACKET ❑99. OTHER <br /> REINFORCED PLASTIC(FRP) ❑10. COATED STEEL <br /> ❑ 5. CONCRETE <br /> TANK INTERIOR LININGDATE INSTALLED <br /> OR COATING ❑ 1. RUBBER LINED ❑ 7. EPDXY LINING ❑ 5 GLASS LINING ❑95. UNKNOWN433 <br /> ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING ❑ 6 UNLINED ❑99. OTHER (For local use only) <br /> (Check one item only) DATE INSTALLED <br /> OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC 113. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN 434 <br /> PROTECTION IF APPLICABLE PROTECTION <br /> ❑ 4. IMPRESSED CURRENT ❑99. OTHER (Fa Iotal use only) <br /> (Check one item only) ❑ 2, SACRIFICIAL ANODE <br /> SPILL AND OVERFILL YEAR INSTALLEDTYPE(For local use only) OVERFILL PROTECTION EQUIPMENT'YEAR INSTALLED <br /> (Check all that apply) ❑ 1 SPILL CONTAINMENT ❑ 1. ALARM ❑ 3. FILL TUBE SHUT CFF VALVE <br /> ❑ 2. DROP TUBE ❑ 2. BALL FLOAT ❑ 4. EXEMPT <br /> ❑ 3. STRIKER PLATE <br /> N. TANK LEAK DETECTION <br /> IF SINGLE WALL TANK(Check all that apply): IF DOUBLE WALL TANK OR TANK WITH BLADDER(Check one item on <br /> ❑ 1, VISUAL(EXPOSED PORTION ONLY) ❑ S. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ 6. VADOSE ZONE ❑ 2. CONTINUOUS INTERSTITIAL MONITORING <br /> ❑ 3. CONTINUOUS ATG ❑ 7. GROUNDWATER ❑ 3. MANUAL MONITORING <br /> ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR)♦ ❑ 8. TANK TESTING <br /> BIENNIAL TANK TESTING ❑99. OTHER <br /> V.TANK CLOSURE INFORMATION)PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YR/MO/DAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL? <br /> gallons ❑Yes ❑No <br /> /TOona a3 �a7/X <br /> CLIPAFORM(4/99) Formerly SWRCB Form B <br />