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Ask -711 IED PROGRAM CONSOLI5ATED FORW T ` UNDERGROUND STORAGE TANKS-TANK PAGE 1 0 1 (t(co P as pt) �- page TYPE OF ACTT7 M 71 NEW SITE PERMIT ❑ 4. ENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Check-one item only) ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWALPERM)T (specify,ewoo-forloca1w,00ly) (specify rearou-tot local we only) ❑ 8 TANK REMOVED 430 tL�l tsmnear ACILrn- AAtFMDRa- Btaer tr-s) FACILITYID: CL/ I CCCCCC 74' � 5 a 3 U 3 LOCATION WITHIN SITE(optional) 1;1 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# 132TA M NUFACTURER 433 COT IP_ARTMENTALIZED TANK Yes ❑ No 434 t!qr, �7 6 0a n Mee d vig If-Yes",complete one page foreach compartment. DATE INSTALLED( AR/MO) Jj5 TANK CAPACITY IN GALLO 136 NUMBER OF COMPARTMENTS 43- 9J..01)v Z ADDITIONAL DESCRIPTION(For local use only) 433 tL TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 01.MOTOR VEHICLE FUEL ❑la REGULAR UNLEADED ❑2. LEADED [:15. JET FUEL (Ifmarked complete Petroleum Type) N'lb. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION FUEL ❑2.NON-FUEL PETROLEUM ❑lc. MIDGRADE UNLEADED ❑4. GASOHOL [199.OTHER [13. CHEMICAL PRODUCT COMMON NAME (from Hazazdous 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 03. SINGLE WALL WITH E3 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one item only) EXTERIOR MEMBRANE LINER ❑95.UNKNOWN P.2. DOUBLE WALL ❑4. SIGNLE WALL IN VAULT [199. OTHER TANS:1,L1,TERI11L-prima-tank Fi. BARE STEEL U3. FIBERGLASS/PLASTIC U 5. CONCRETE 0 95. UNKNOWN 444 (Check one item only) ❑2 ST.kINLESS STEEL [14. STEEL CLAD W/FIBERGLASS ❑8 FRP COI%IPTIBLE WV 100001`IETHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) TANK 1,LYTERIAL-secondarvtank 1. BARE STEEL 3. FIBERGLASS/PLASTIC 0 5. CONCRETE 95. UNKNOWN 145 (Check was item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑8 FRP COIHgMLE R'100'a I IETILaNOL ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10.COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING 1.RUBBER LINED 0 3.EPDXY LINING 0 5.GLASS LINING 9P5.UNKNOWN 446 DATE INSTALLED 44- OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING ❑6 UNLINED ❑99 OTHER (Check one item only) (For local we only) 441 DATE INSTALLED 119 OTHER CORROSION ❑1 ALINUFACTURED CATHODIC ❑3 FIBERGLASS REINFORCED PLASTIC 95 UNKNOWN PROTECTION IF APPLICABLE PROTECTION ❑4 IMPRESSED CURRENT ❑99 OTHER (Check oneamr only) ❑2 SACRIFICIAL ANODE (For local use only) SPELL AND OVERFILL YEAR INSTALLED 450 TYPE pocal use may) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Check ail that apply) %l SPILL CONTAINMENT ❑1 ALARM ❑3 FILL TUBE SHUTOFF VALVE pa 2 DROP TUBE F2 BALL FLOAT ❑4 EXEMPT 3 STRIKER PLATE IV.TANK LEAK DETECTION(A description of the monitoring program shall be submtned to the local agency.) IF SINGLE WALL TANK(Chackothat pply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 (Check one item only) ❑1 VISUAL(EXPOSED PORTION ONLY) ❑5 hLWLTAL TANK GAUGING(Ia1T(3) ❑1 VISUAL(SINGLE WALL IN VAULT ONLY) ❑2 AUTOMATIC TANK GAUGING(ATG) ❑6 VADOSE ZONE �C2 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 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 45 gallons ❑Yes ❑ No UPCF(12199 revised) 10 Formerly SWRCB Form B