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Ask IED PROGRAM CONSOLIDATED F0FJW r UNDERGROUND STORAGE TANKS--TANK PAGE 1 (two Pa cant> Page TYPE OF ACTION I NEW SITE PERMIT ❑ 4 UIENDED PERMIT [35 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Check me item aol ❑ 7 PERMANENTLY CLOSED ON SITE ERMIT (Specdj-reaaon-forlocaloaeady) (Specrfi'reaaou-for local we only) ❑ 8 TANK REMOVED 430 (s e Facn. "N.� anB.a- sm*ureseAa) FACII.ITYID: 1 �1��(�� v v til LOCATION WITHIN SITE(optimal) 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 T MA FACTURE 433 CONIPARTI\IENT.ALIZED TANK Yes ❑ No 434 16q 2;,6 X, If"Yes",complete one page for each compsamem. DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 43' � ADDITIONAL DESCRIPTION(For bcal use D only) 438 H.TANK CONTENTS TANK USE 139 PETROLEUM TYPED 1. MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED E32-LEADED, ❑5. JET FUEL (Ifteaked completePeudeum Type) ❑lb. PREMIUM UNLEADED K3.DIESEL ❑6. AVIATION FUEL ❑2.NON-FUEL PETROLEUM [3 It. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER ❑3. CHEMICAL PRODUCT COMMON NAME (from Hawdous Materials bveoarypage) 111 CAS#(Gom Haaardoos Materials Inventory page) 442 ❑4. HAZARDOUS WASTE (Includes used Oil) ❑95.UNKNOWN III. TANK CONSTRUCTION TYPE OF TANK 1. SINGLE W ALL 03. SINGLE WALL WITH E3 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 113 (Chock one item only) EXTERIOR MEMBRANE LINER ❑95. UNKNOWN 2. DOUBLE WALL [14. SIGNLE W ALL IN VAULT ❑99. OTHER TANm K 1,LATERIAL-pnary tank 1.BARE STEEL 3. FIBERGLASS/PLASTIC 5. CONCRETE 95. UNKNOWN 444 (Check one*m only) 0 ST.AINLESS STEEL [34. STEEL CLAD W/FIBERGLASS ❑8 FRP COZ,IPTIBLE W 100°o HEPILANOL 1199-OTHER REINFORCED PLASTIC(FRP) T.ANKILATERIAL-aemndan-taok 1.BARE STEEL 3.FIBERGLASS/PLASTIC 5. CONCRETE 95. UNKNOWN 415 (Chock one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑8 FRP COMPTIBLE WfI00'e 1`1ETHANOL ❑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 we only) 448 DATE INSTALLED 419 OTHER CORROSION ❑1 I`LANC)F-NCTURED CATHODIC ❑3 FIBERGLASS REINFORCED PLASTIC X95 UNKNOWN PROTECTION IF APPLICABLE PROTECTION ❑4 IMPRESSED CURRENT ❑99 OTHER (Chale me item only) ❑2 SACRIFICIAL ANODE (For lord one Dahl SPILL AND OVERFILL YEAR INSTALLED 450 TYPE(local uscoaly) 451 OVERFILL PROTECTION EQUB'MENT:YEAR INSTALLED 4-2 (Check an dot apply) If SPILL CONTAINMENT 131 ALARM ❑3 FILL TUBE SHUT OFF VALVE 2 DROP TUBE 2 BALL FLOAT ❑4 EXEMPT 3 STRIKER PLATE IV.TANK LEAK DETECTION(A descriptionof the montbrmg program shall be submitted to the local agency.) IF SINGLE WALL TANK(Check alt that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 (Check one item only) ❑I VISUAL(EXPOSED PORTION ONLY) ❑1I LANL?AL TANK GAUGING(I,ITO) ❑1 VISUAL(SINGLE WALL IN VAULT ONLY) ❑2 AUTOMATIC TANK GAUGING(ATG) [:16 VADOSE ZONE )K2 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 1S6 TANK FILLED WITH INERT MATERIAL? 45 REMAINING P llons ❑Yes Q No UPCF(12199 revised) 10 Formerly SWRCB Form B