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• low FLED PROGRAM CONSOLIDATED FO { t5 UNDERGROUND STORAGE TANKS-TANK PAGE i (taco pages per fa Page of TYPE OF ACTIO Al NEW SITE PERMIT 4.-NI�IENDED PEUIIT ❑ 5 CHANGE OF INFORMATION ❑6 TEMPORARY SITE CLOSURE � (Check one item only) ❑ 7 PERMANENTLY CLOSED ON SITE ❑ PERMIT (Specifi.mwoo_fortocaloreooly) (Specit,r oo_foilocalmseoal> ❑ 8 TANK REMOVED x311 BU SS 11�iE(Saone a�F�eH r x. tE«DBS no Bn mex .�) FACILIT ID: l G � " � sS LOCATION THIN SITE(Optimal) T31 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 TA'Nj��(/�Kj�MANUFACTURER 433 CON IP_ARTNIENTALIZED TANK ❑Yes No Tia �/. /"G /s.'.A W l t If"Yes",complete one page for each compartment. DATE INSTALLED(YEA u��ir�}' TANK CAPACITY IN GALLO 436 NUMBER OF COMPARTMENTS 43 1 ovv ADDITIONAL DESCRIPTION(For local use only) Tis U.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 44 1. MOTOR VEHICLE FUEL fifla. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (Ifmaked complete Petmkem Type) ❑Ib. PREMIUM UNLEADED [13.DIESEL ❑6. AVIATION FUEL ❑2. NON-FUEL PETROLEUM ❑lc. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER ❑3. CHEMICAL PRODUCT COMMON NAME (from Hazadats Malerials Inventory page) 441 CAS#(from Hazardous Materials Inventory page) 'U2 ❑4. HAZARDOUS WASTE (Includes Used Oil) ❑95.UNKNOWN HL TANK CONSTRUCTION TYPE OF TANK 1. SINGLE WALL 3. SINGLE WALL WITH 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one item only) EXTERIOR MEMBRANE LINER [395.UNKNOWN 02. DOUBLE WALL ❑4. SIGNLE W ALL IN VAULT [399. OTHER TANK 1,LA,TERIAL-pnmary tank L BARE STEEL 3. FIBERGLASS/PLASTIC 5. CONCRETE 95. UNKNOWN TT4 (Check ow item only) ❑2 STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑8 FRP COI`IPTIBLE W,I00°o METHANOL ❑99,OTHER REINFORCED PLASTIC(FRP) TANK 2 LaTERIAL-second--tack 1. BARE STEEL 3. FIBERGLASS/PLASTIC 0 5. CONCRETE 0 95. UNKNOWN 445 (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑8. FRP C01,•IPTIBLE Wi100"o 1,IETI-LANOL ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10.COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING 0 1.RUBBER LINED ❑3.EPDXY LINING ❑5.GLASS LINING 95.UNKNOWN 446 DATE INSTALLED 44- OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING ❑6 UNLINED ❑99 OTHER (Check one item only) (For local use only) 448 DATE INSTALLED 449 OTHER CORROSION ❑1 IL_vRTFA(-nTRED CATHODIC ❑3 FIBERGLASS REINFORCED PLASTIC �r5 UNKNOWN PROTECTION IF APPLICABLE PROTECTION ❑4IMPRESSED CURRENT ❑99 OTHER (Check ore item only) ❑2 SACRIFICIAL ANODE (For local rrae acyl SPILL AND OVERFILL YEAR INSTALLED 450 TYPE([me]use only) 451 OVERFILL PROTECTION EQUIPMENTNEAR INSTALLED 452 (Check all that apply) )ff l SPILL CONTAINMENT ❑I ALARM ❑3 FILL TUBE SHUT OFF VALVE 92 DROP TUBE W2 BALL FLOAT ❑4 EXEMPT 3 STRIKER PLATE IV.TANK LEAK DETECTION(A description of the monitoring program shall he submitted m the local agency.) IF SINGLE WALL TANK(Check ell that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 (Check oar item only) ❑I VISUAL(EXPOSED PORTION ONLY) ❑51 VUR1AL TANK GAUGINO 0,1TO) ❑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 IV.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) T`5 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 45G TANK FILLED WITH INERT MATERIAL? 4` gallons [I No ❑ UPCF(12199 revised) 10 Formerly SWRCB Form B