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IPWIED PROGRAM CONSOLIDATED FO $\ TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 1 q) l I°3 (two pagan �) Pap_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-only) (Specify reason-for local use only) ❑ 8 TANK REMOVED 430 BUSINESS NAME SmneasFACIIfIYNAMHorDBA-DoingBa�neasAs) FACILITY ID: i `L rdiG� �At 3 LOCATION WITHIN SITE(optional) 431 L TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landtmarlm shall be submitted to the local geacy.) TANK ID# 432 TANK MANUFACTVRER 433 COMPARTMENTALIZED TANK ❑Yes WN. 434 >"lzQ ! �' �Q�t t if••Yes",canplete one page for each compeIIment. DATE INSTALL (YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 99/ rr, Gnu J ADDITIONAL DESCRIPTION(Foriowl ae ody) 438 H.TANK CONTENTS M11" �TANK USE 439 PETROLEUM TYPE 440 L'1 1.MOTOR VEHICLE FUEL le_ REGULAR UNLEADED ❑2 LEADED ❑5. JET FUEL (ifin dcompiete Petroleum Type) ❑1b. PREMIUM UNLEADED [13- DIESEL ❑6. AVIATION FUEL [12. NON-FUEL PETROLEUM ❑1 c. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER ❑3. CHEMICAL PRODUCT COMMON NAME (from Hazmdons Meteusis Inventory page) 441 CAS#(from Hmrdoos Materiels inventory page) 442 ❑4.HAZARDOUS WASTE f� �J9 �7�y,s, rye/ (Includes Used Oil) i,y / �(V�1(� U l�' 2 `V r" 3 ' " ❑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 dem only) // EXTERIOR MEMBRANE LINER ❑95. UNKNOWN 13 DOUBLE WALL [14. SIGNLE WALL IN VAULT ❑99. OTHER TANK MATERIAL-primary tank ❑1. BARE STEEL RYFIBERGLASS/PLASTIC 5. CONCRETE 0 95. UNKNOWN 444 (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS [18. FRP COMPTIBLE W/100a/o METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary tank ❑I. BARE STEEL 3. FIBERGLASS/PLASTIC El 5. CONCRETE 0 95. UNKNOWN 445 (Check one item only) ❑2 STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPTIBLE W/100%METHANOL [199.OTHER REINFORCED PLASTIC(FRP) ❑10.COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING 1.RUBBER LINED ❑3.EPDXY LINING S.GLASS LINING 95.UNKNOWN 446 DATE INSTALLED 447 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING ❑6 UNLINED ❑99 OTHER (Check one item only) (For local use only) OTHER CORROSION ❑I MANUFACTURED CATHODIC WiFIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN 448 DATE INSTALLED 449 PROTECTION IF APPLICABLE PROTECTION [14 IMPRESSED CURRENT ❑99 OTHER (Check one item arty) ❑2 SACRIFICIAL ANODE (Forlocal-only) SPILL AND OVERFILL YEAR INSTALLED - 450 TYPE(local use only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (ick an that may) ii-I SPILL CONTAINMENT QT ❑3 FILL TUBE SHUT OFF VALVE ['2 DROP TUBE CK BALL FLOAT ❑4 EXEMPT ❑3 STRIKER PLATE IV.TANK LEAK DETECTION(A desorption of the monitoring program shall be submitted to the local agency.) IF SINGLE WALL TANK(check an that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 (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 V ADOSE 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/MOIDAY) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 gallons ❑Yes ❑ No UPCF(12/99 revised) 10 Formerly SWRCB Form B