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r� UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 35� two pages per tank) Page of TYPE OF ACTION ❑ 1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (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: I USA GASOLINE #3 So 3 LOCATION WITHIN SITE (Optional) 431 1. TANK DESCRIPTION (A scaled plot plan with the location ofthe UST system including buildings and landmarks shall be submitted to the local agency.) TANK ID # 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK EJ Yes No 434 X1,4 0 TRUSCO If"Yes", complete one page for each compartment. DATE INSTALLED (YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 1995 10000 ADDITIONAL DESCRIPTION (For local use only) 438 II. TANK CONTENTS TANK USE 439 PETROLEUM TYPE ® 1. MOTOR VEHICLE. FUEL 440 ❑ la. REGULAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL (If marked complete Petroleum Type) ® lb. PREMIUM UNLEADED ❑ 3. DIESEL [16. AVIATION FUEL [12. NON-FUEL PETROLEUM ❑ Ic. MIDGRADE UNLEADED [14. GASOHOL ❑ 99. OTHER ❑ 3. CHEMICAL PRODUCT COMMON NAME (from Hazardous Materials Inventory page) 441 CAS# (from Hazardous Materials Inventory page) 442 ❑ 4. 1IAZARDOUS WASTE (Includes Used Oil) ❑ 95 UNKNOWN III. 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 ❑ 95. UNKNOWN ® 2. DOUBLE WALL ❑ 4. SIGNLE WALL IN VAULT ❑ 99. OTHER TANK MATERIAL -primary tank ® 1. BARE STEEL ❑ 3. FIBERGLASS / PLASTIC ❑ 5. CONCRETE ❑ 95. UNKNOWN 444 (Check one item only) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD W/FIBERGLASS ❑ 8. FRP COMPTIBLE W/100% METHANOL ❑ 99 OTI-MR REINFORCED PLASTIC (FRP) TANK MATERIAL -secondary tank ❑ 1. BARE STEEL E3 3. FIBERGLASS/ PLASTIC ❑ 5. CONCRETE ❑ 95. UNKNOWN 445 (Check one item only) ❑ 2. STAINLESS STEEL ® 4. STEEL CLAD W/FIBERGLASSa ❑ 8. FRP COMPTIBLE W/100% METHANOL ❑ 99, OTHER REINFORCED PLASTIC (FRP) ❑ 10. COATED STEEL ❑ 5 CONCRETE TANK INTERIOR LINING El l RUBBER LINED 0 3. EPDXY LINING 5. GLASS LINING 95. UNKNOWN 446 DATE INSTALLED 447 OR COATING ❑ 2 ALKYD LINING ❑ 4 PHENOLIC LINING 06 iJNLINED ❑ 99 OTHER (Check one item only) (For local use only) • OTHER CORROSION ❑ 1 MANUFACTURED CATHODIC ❑ 3 FIBERGLASS REINFORCED PLASTIC ❑ 95 UNKNOWN 448 448 PROTECTION IF APPLICABLE PROTECTION ❑ 4IMPRESSED CURRENT ❑ 99 OTHER (Check one item only) ❑ 2 SACRIFICIAL ANODE (For local nue only) SPILL AND OVERFILL YEAR INSTALLED 450 'TYPE (local use only) 451 OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 452 (Check all that apply) ® 1 SPILL CONTAINMENT 1995 ❑ 1 ALARM ®3 FILL TUBE SHUTOFF VALVE ®2 DROP TUBE 1995 ❑ 2 BALL FLOAT ❑ 4 EXEMPT ® 3 STRIKER PLATE 1995 IV. TANK LEAK DETECTION (A description of the 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 ❑ 1 VISUAL (EXPOSED PORTION ONLY) El MANUAL TANK GAUGING (MTG) (Check one item orgy) ❑ 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 ESTATATED QUANTITY OF SUBSTANCE REMAINING 456 'TANK FILLED WI"1'H INERT MATERIAL? 457 gallons Eles ❑ No UPCF (1/99 revised) Formerly SWRCB Form B