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NIFIED PROGRAM CONSOLIDATED FOR TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 1 (two pages per tank) Page _ of TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 4.AMENDED PERMIT ILi.S. CHANGE OF INFORMATION) ❑ 6. TEMPORARY SITE CLOSURE (Check one dem only) / _ ❑ 7. PERMANENTLY CLOSED ON SITE a ❑3.RENEWAL PERMIT (Specify reason-for local use only) (Specify change-for local use only) ❑ 8. TANK REMOVED 430 BUSINESS NAME(Same as FACILITY 14ME or DBA-Doing Business As) FACILITY IDN 1 LOCATIONWITHIN SITE(Optic , �, _) 431 � O /�V(�/' 1.TANK DESCRIPTION NK ID Is F,3 2'� /� TANK MANU .. COMPARTMENTALIZED TANK ❑ Yes ❑ eNo n SI ll�lyl C N"YesZ complete one page for each compartment. DATE INSTALLED(YEAR/MO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS ff 010 1 4000 ADDITIONAL DESCRIPTION(Forlocal use only) IL TANK CONTENTS TANK USE 432 PETROLEUM TYPE a^'�'" MOTOR VEHICLE FUEL ❑1a. REGULAR UNLEADED ❑l 2. LEADED ❑ 5. JET FUEL (If manned,complete Petroleum Type) ❑1b. PREMIUM UNLEADED ). DIESEL ❑ 6. AVIATION FUEL ❑ 2. NON-FUEL PETROLEUM ❑1c MIDGRADE UNLEADED ❑ 4. GASOHOL ❑99. OTHER ❑ 3. CHEMICAL PRODUCT ❑ 4. HAZARDOUS WASTE(Includes COMMON NAME(fmm Hazardous Materials Inventory page) CAS N(from Hazardous Materials Inventory page) Used OiO 95, UNKNOWN IIL TANK CONSTRUCTION TYPE OF TANK ��❑yyy1. SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM (Check one dem only) , DOUBLE WALL EXTERIOR MEMBRANE LINER 1195. UNKNOWN ❑ 4. SINGLE WALL IN A VAULT 1199. OTHER TANK MATERIAL-primary tank ❑ 1 BARE STEELS. FIBERGLASS/PLASTIC ❑ 5. CONCRETE ❑95. UNKNOWN (Check one item only) ❑ 2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑ 8. FRP COMPATIBLE W/100%METHANOL ❑99. OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary tank ❑ 1 BARE STEEL FIBERGLASS/PLASTIC ❑ 8. FRP COMPATIBLE W/100%METHANOL ❑95..UNKNOWN (Check one item only) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD W/FIBERGLASS ❑ 9. FRP NON-CORRODIBLE JACKET ❑99. OTHER REINFORCED PLASTIC(FRP) 1110. COATED STEEL ❑ 5. CONCRETE TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING ❑95. UNKNOWN433 DATE INSTALLED ORCOATNG ❑ 2.ALKYD LINING ❑ 4. PHENOLIC LINING Xe. UNLINED ❑99. OTHER (Check one item only) (For local use only) OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC FIBERGLASS REINFORCED PLASTIC 1195. UNKNOWN 434 DATE INSTALLED PROTECTION IF APPLICABLE PROTECTION ❑ 4. IMPRESSED CURRENT ❑99. OTHER (Check one item only) ❑ 2. SACRIFICIAL ANODE (For local use only) SPILL AND OVERFILL YEAR INSTALLED TYPE(For local use only) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED (Check all that apply) ❑ 1 SPILL CONTAINMENT ❑ 1. ALARM ❑ 3. FILL TUBE SHUT OFF VALVE ❑ 2. DROP TUBE ❑ 2. BALL FLOAT ❑ 4. EXEMPT ❑ 3. STRIKER PLATE _,.IV.`�TAN I.CrJtIC IF SINGLE WALL TANK Check ad that apply): IF DOUBLE WALL TANK OR TANK WITH BLADDER(Check one item only): ❑ 1, VISUAL(EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY) ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ 6. VADOSE ZONE 2. CONTINUOUS INTERSTITIAL MONITORING ❑ 3. CONTINUOUS ATG ❑ 7. GROUNDWATER ❑ 3. MANUAL MONITORING ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR)+ ❑ 8. TANK TESTING BIENNIAL TANK TESTING - ❑99. OTHER V.TANK CLOSURE INFORMATION/PERMANENTCLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 1 TANK FILLED WITH INERT MATERIAL? gallons ❑Yes ❑No f 0, I-qq CUPAFORM(4/99) Formerly SWRCB Form B