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f5 I Je UNIFIED PROGRAM CONSOLIDATED FORM ` V� m TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 (two pages per bink) TYPE OF ACTION 111 NEW SITE PERMIT ❑ 4 AMENDED PERMIT A5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE page of (Check one item only) ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT (Specify reason -for local use only) (Specify reason -for local use only) ❑ 8 TANK REMOVED 430 BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business As) FACILITY ID: USA GASOLINE #3 542�0- 3TT LOCATION WITHIN SITE (Optional) 431 I. TANK DESCRIPTION (A scaled plot plan with the location of the UST system TANK ID # 432 TANK MANUFACTURER 13ATEINSTALLED 1995 ADDITIONAL DES( TANK USE ® I. MOTOR VEHICLE FUEL (If marked complete Petroleum Type) ❑ 2. NON -FUEL PETROLEUM ❑ 3. CHEMICAL PRODUCT ❑ 4. HAZARDOUS WASTE (Includes Used Oil) ❑ 95. UNKNOWN TYPE OF TANK (Check one item only) TANK MATERIAL -primary tank (Check one item only) TANK MATERIAL - secondary tank (Check one item only) TANK INTERIOR OR COATING (Check one item only) TRUSCO �) 435 TANK CAPACITY IN GALLONS 12000 (For local use only) II. TANK CONTENTS buildings and landmarks shall be submitted to the local agency.) 13 COMPARTMENTALIZED TANK ❑ Yes _0N. If"Yes", complete one page for each compartment. NUMBER OP COMPARTMENTS PETROLEUM TYPE ® la. REGULAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL ❑ 1 b. PREMIUM UNLEADED ❑ 3. DIESEL, ❑ 6. AVIATION FUEL ❑ I . MIDGRADE UNLEADED ❑ 4. GASOHOL ❑ 99. OTHER COMMON NAME (from Hazard.. Materials Inventory page) 441 CAS# (from Hazardous Materials Inventory page) ❑ 2 ALKYD LINING ❑ 4 PHENOLIC LINING ®6 UNLINED ❑ 99 OTHER 434 437 438 440 443 445 III. TANK CONSTRUCTION ❑ I. SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM (Check one item only) ❑ 2 SACRIFICIAL ANODE EXTERIOR MEMBRANE LINER ❑ 95. UNKNOWN ® 2. DOUBLE WALL. ❑ 4. SIGNLE WALL IN VAULT ❑ 99. OTHER ® 1. BARE STEEL ❑ 3. FIBERGLASS/ PLASTIC E15 CONCRETE ❑ 95. UNKNOWN ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD W/FIBERGLASS ❑ 8. FRP COMPTIBLE W/ 100% METHANOL 1:199 OTHER IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 REINFORCED PLASTIC (FRP) one item only) (❑ 1 VISUAL (SINGLE WALL IN VAULT ONLY) ❑ 1. BARE STEEL ❑ 3. FIBERGLASS / PLASTIC ❑ 5. CONCRETE ❑ 95. UNKNOWN ❑ 2. STAINLESS STEEL ® 4. STEEL CLAD W/FIBERGLASS ❑ 8. FRP COMPTIBLE W/100% METHANOL ❑ 99. OTHER (SIR) BIENNIAL TANK TESTING ❑ 99 OTHER REINFORCED PLASTIC (FRP) ❑ 10. COATED STEEL ESTIMATED DATE LAST USED (YR/MO/DAY) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT' MATERIAL? 457 ❑ 5. CONCRETE gallons 1. RUBBER LINED 3. EPDXY LINING LJ 5. GLASS LINING 0 95. UNKNOWN 446 DACE INSTALLED ❑ 2 ALKYD LINING ❑ 4 PHENOLIC LINING ®6 UNLINED ❑ 99 OTHER 434 437 438 440 443 445 (For local use otdy) OTHER CORROSION ❑ 1 MANUFACTURED CATHODIC ❑ 3 FIBERGLASS REINFORCED PLASTIC ❑ 95 UNKNOWN 448 448 PROTECTION IF APPLICABLE PROTECTION ❑ 4 IMPRESSED CURRENT 1199 OTHER (Check one item only) ❑ 2 SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED 450 TYPE (local use only) 451 (For local use only) OVERFILL PROTECTION EQUIPMENT: YEARINSTALLED 452 (Check all that apply) ® 1 SPILL CONTAINMENT 1995 ® 2 DROP TUBE 1995 ❑ 1 ALARM ® 3 FILL TUBE SHUT OFF VALVE ® 3 STRIKER PLATE 1995 ❑ 2 BALL FLOAT ❑ 4 EXEMPT IV. TANK LEAK DETECTION (A description of file monitoring program shall be submitted to the local agency.) IF SINGLE WALL TANK (Check all that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 ❑ I V1S(JAL (EXPOSED PORTION ONLY)Check ❑ 5 MANUAL TANK GAUGING (MTG) one item only) (❑ 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 ❑ 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? 457 gallons ❑ Yes ❑ No UPCF (1/99 revised) Formerly SWRCB Form B