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D P NSA A D TANKS UNDERGROUNDST A - T F 1 (two paw p-�) Page_of_ TYPE OF ACTION ❑1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT ® 5 CHANCE OF INFORMATION ❑ 6 TEMPORARY WE CLOSURE (Check one it m only) ❑ 7 PERMANENTLY Y CLOSED ON SITE ❑ 3 RENBWALPERMrT (Specify reason-forlocaluseonly) (Specify reason-for local use only) S TANK REMOVED 430 _71 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID: l _ SBC#ESCLCAII LOCATION WITHIN SITE(Optional) 431 L TANK DESCRIPTION (A scaled plot pian with the location ofthe UST system including buildings and landwx&s shall be submitted to the local agency.) TANK ID# 432 TANK MANUFACTURER 433 COWARTMWrALIZED TANK ❑Yes 0 No 434 2 Poor If"Yes",wmplete one page for each oomparhnent DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 Unknown 500 ADDITIONAL DESCRIPTION(For kxw use orgy) 438 U.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 ®1.MOTOR VEHICLE FUEL ®Ia. REGULARUNLEADED [12. LEADED ❑5. JET FUEL (Ifmarked complete Petroleum Type) 13 Ib. PREMIUMUNLEADED N3. DIESEL 06. AVIATION FUEL ❑2.NON-FUEL PETROLEUM ❑lo. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER_ ❑3. CHEMICAL PRODUCT COMMON NAME (from Hazardous Materials hwentory page) 441 CAS#(franc Hazardous Maters hrverrtory page) 442 ❑4. HAZARDOUS WASTE (Inch7des Used Oil) ❑95.UNKNOWN M. TANK CONSTRUCTION TYPE OF TANK 0 1. SINGLE WALL 3. SINGLE WALL WITH 0 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Cheokoneitemonly) EXTERIOR MEMBRANE LINER 095. UNKNOWN N 2. DOUBLE WALL ❑4. sIGNLE WALL IN VAULT [199. OTHER_ TANKMATERIAL-pnmarytank 9 1.BARE STEEL 3. FIBERGLASS/PLASTIC 5. CONCRETE 0 95.UNKNOWN 444 (Check one item only) ❑2. STAINLESS STEEL [14. STEEL CLAD W ERGLASS ❑a.FRP COMPTIBLE W/Io0%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary tank 1. BARE STEEL 3. FIBERGLASS/PLASTIC 5. CONCRETE 0 95. UNKNOWN 445 (Chi oneitem only) ❑2. STAINLESS STEEL N 4. STEEL CLAD W/FiBERGLASS ❑a. FRP COMPTIBLE W1100%METHANOL [199.OTHER REINFORCED PLASTIC(FRP) ❑10.COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING 1.RUBBER LINED 3,EPDXY LINING El 5.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 kxxl 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 loom use only) SPILL AND OVERFILL YEAR INSTALLED 450 TYPE(iocai use y) 451 OVERFILL PROTECTION EQUHWENT:YEAR INSTALLED 452 (Chock all that apply) N 1 SPILL CONTAINMENT Unk N 1 ALARM Unk ❑3 FILL TUBE SHUT OFF VALVE ®2 DROP TUBE Unk ❑2 BALL FLOAT ❑4 EXEMPT ®3 STRIKER PLATE link IV.TANK LEAK DETECTION(A descopkenofihemonitomrgprogram shall besubmittedtothe local agency) IF SINGLE WALL TANK(Check all that apply) 453 IF RUBLE WALL TANK OR TANK WITH BLADDER 454 (Check one iters only) ❑1 VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(R2TG) ❑1 VISUAL(SINGLE WALL IN VAULT ONLY) ❑2 AUTOMATIC TANK GAUGING(ATG) ❑6 V ADOSE ZONE N 2 CONTINUOUS INTERSTITIAL MONITORING ❑3 CONTINUOUS ATG ❑7 GROUNDWATER ❑3 MANUAL MONITORING ❑4 STATISTICAL INVENTORY RECONCILIATION ❑a TANKTESTING (SIR) BIENNIAL TANK TESTING ®99 OTHER IV.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MOIDAY) 455 ESTIMATED QU OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 gallons ®Yes 0 No