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UNIFIED PROGRAM CONSOLIDATED FORM /j/tp/bZ TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 1 (two pages per tank) Page _of_ TYPE OF ACTION ❑L NEW SITE PERMIT [:14. AMENDED PERMIT ®5. CHANGE OF INFORMATION) ❑6. TEMPORARY SITE CLOSURE (Check one item only) ❑7. PERMANENTLY CLOSED ON SITE ❑3. RENEWAL PERMIT E-18. TANK REMOVED 430 (Sped reason-for local use only) (Specify change-for locol use only) BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3FACILITYID* I Circle K Stores, Inc. #2705447/05447 r ��?� LOCATION WITHIN SITE(Optional) 431 I.TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitter/to the local agency) TANK ID# 432 TANK:KA433 COMPARTMENTALIZED TANK ❑ Yes No 434 /� D✓O /q.A 4 �-� ( If�YesCl,complete one page for each co partment. DATE INSTAL (YEAR(MO) /! l(/ 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 � b do ADDITIONAL DESCRIPTION(For local use only) 438 II.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 I. MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL (Ij rked,complete Petroleum Type) PREMIUM UNLEADED ❑ 3. DIESEL ❑ 6. AVIATION FUEL ❑ 2. NON-FUEL PETROLEUM ❑Ic. MIDGRADE UNLEADED ❑ 4. GASOHOL ❑99. OTHER ❑3. CHEMICAL PRODUCT ❑ 4. HAZARDOUS WASTE(Includes COMMON NAME(from Hazardous Materials Inventory page) 441 CAS#(from Hazardous Materials Inventorypage) 442 Used Oil) ❑95 XERXES III.TANK CONSTRUCTION TYPE OF TANK ❑1, SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 2. DOUBLE WALL EXTERIOR MEMBRANE LINER [:]95. XERXES (Check one item only) ❑ 4. SINGLE WALL IN A VAULT ❑99. OTHER TANK MATERIAL-primary tank ❑1 BARE STEEL FIBERGLASS/PLASTIC [:]5. CONCRETE ❑95. XERXES 444 (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. XERXES 445 (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑9. FRP NON-CORRODIBLE JACKET ❑99. OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑3. EPDXY LINING ❑5. GLASS LINING ❑95. XERXES 446 DATE INSTALLED 447 OR COATING ❑2. ALKYD LINING ❑4. PHENOLIC LINING �. UNLINED ❑99. OTHER Check one item on! For local use only) OTHER CORROSION ❑I. MANUFACTURED FIBERGLASS REINFORCED PLASTIC ❑95. XERXES 448 DATE INSTALLED 449 PROTECTION IF APPLICABLE CATHODIC ❑4. IMPRESSED CURRENT ❑99. OTHER PROTECTION (Check one item only) ❑2 SACRIFICIAL ANODE (For local use only) SPILL AND OVERFILL YEAR INS1T�{ 450 TYPE(For local use on/y) 451 OVER PROTECTION EQUIkM�E/y,T:YEAR INSTALLED 4 452 Qty, SPILL CONTAINMENT l [:11. ALARM �9. FILL TUBE SHUT OFF VALVE (Check all that apply) `'Sa�� /LTJ` DROPTUBE ❑2. BALL FLOAT 4. EXEMPT STRIKER PLATE IV. TANK LEAK DETECTION (A description ofthe monitoringprogram shall besubmitted to the local agency.) IF SINGLE WALL TANK(Check all that apply): 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER(Check one item only): 454 ❑1, VISUAL(EXPOSED PORTION ONLY) ❑5. MANUAL TANK GAUGING(MTG) [:]I. VISUAL(SINGLE WALL IN VAULT ONLY) ❑2. AUTOMATIC TANK GAUGING(ATG) ❑6. VADOSE ZONE 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/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 gallons E Yes :J No UPCF(1/99 revised) Formerly SWRCB Form B