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Afta k.7 t/ IED PROGRAM CONSOLIDATED FO ' TANKS UNDERGROUND STORAGE TANKS-TANK PAGE i (two pages per tank) F. Page�of TYPE OF ACTION N1 NEW SITE PERMIT ❑ 4 AhBEIDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑6 TEMPORARY SITE CLOSURE (Chock ouetem only) ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT (Speeifyrexon-forlocalweady) (Specifl•teamn-for local weonly) ❑ 8 TANK REMOVED yin BU INESS AlvIE(Sme Fa(R I;1 NAb,IE a DBwme*a Al FACELIT)(ID: I aij 76 LOCATION WITHIN SITE(optioae) 431 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# / 432 TANY,MANUFACTURER 433 COI\-IPARTIvIENTALIZED TANK ❑Yes No 434 '�t If"Yes",complete one page for each comportment. DATE INSTALLEDW(YEAP TANK CAPACITY IN GALLO 4-16 NUMBER OF COMPARTMENTS 437 1 avv ADDITIONAL DESCRIPTION(For local use mly) 43S EL TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 A 1. MOTOR VEHICLE FUEL Xla. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (Ifmorlmd complete Petroleum Type) ❑lb. PREMIUM UNLEADED ❑3.DIESEL ❑6. AVIATION FUEL ❑2. NON-FUEL PETROLEUM ❑lc. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER ❑3. CHEMICAL PRODUCT COMMON NAME (from Hdom;Materials Invenaoty page) 441 CAS#(from Hazardous Materials laventory page) " azor ❑4: HAZARDOUS WASTE (1ncludesUsed Oil) ❑95.UNKNOWN IIL TANK CONSTRUCTION TYPE OF TANK 0 1. SINGLE WALL 0 3. SINGLE WALL WITH 5.SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check me item only) EXTERIOR MEMBRANE LINER ❑95.UNKNOWN M2. DOUBLE WALL ❑4. SIGNLE W ALL IN VAULT ❑99. OTHER TANK&LATERIAL-Priarary tank 1. BARE STEEL 3. FIBERGLASS/PLASTIC 5. CONCRETE 95. UNKNOWN 414 (Check one item only) ❑'_ STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑8 FRP COMPTIBLE W/10o METHANOL Q 99-OTHER REINFORCED PLASTIC(FRP) TAK h NLATERIAL-secondary tank 1. BARE STEEL 3.FIBERGLASS/PLASTIC 5. CONCRETE 95. UNKNOWN ` (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑8. FRP(-OI\IPTIBLE W/lo0°u METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10.COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING 0 1.RUBBER LINED [13.EPDXY LINING ❑5.GLASS LINING 95.UNKNOWN 446 DATE INSTALLED 44� OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING ❑6 UNLINED ❑99 OTHER (For local we only) (Check one item only) 448 DATE INSTALLED 449 OTHER CORROSION ❑1 bLAN?TFAI'TURED C-aTHODIC ❑3 FIBERGLASS REINFORCED PLASTIC V§5 UNKNOWN PROTECTION IF APPLICABLE PROTECTION [14 IMPRESSED CURRENT ❑99 OTHER (Check one item only) ❑2 SACRIFICIAL ANODE (Fa kkalnse only) SPELL AND OVERFILL YEAR INSTALLED 45o TYPE(local rue may) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED (Checkall that apply) 01 SPILL CONTAINMENT ❑1 ALARM ❑3 FILL TUBE SHUT OFF VALVE Pd2 DROP TUBE Rr2 BALL FLOAT ❑4 EXEMPT 3 STRIKER PLATE IV.TANK LEAK DETECTION(A descnphoo of the manhmmg proms shall be suhmitted to the local agency.) IF SINGLE WALL TANK(Check all that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 (Check one item oily) ❑I VISUAL(EXPOSED PORTION ONLY) ❑S KEANE?AL TANK(3.kuoiNG afm) ❑1 VISUAL(SINGLE WALL IN VAULT ONLY) ❑2 AUTOMATIC TANK GAUGING(ATG) ❑6 VADOSE ZONE X2 CONTINUOUS INTERSTITIAL MONITORING ❑3 CONTINUOUS ATG ❑7 GROUNDWATER ❑3 MANUAL MONITORING ❑4 STATISTICAL INVENTORY RECONCILIATION ❑8 TANK TESTING (SIR) BIENNIAL TANK TESTING ❑99 OTHER W.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 4SG ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FII LED WITH INERT MATERIAL? 45 gallons ❑Yes ❑ No UPCF(12/99 revised) 10 Formerly SWRCB Form B