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UNIFIED PROGRAM CONSOLIDATED FORM �y TANKS ✓�`O`✓ UNDERGROUND STORAGE TANKS -TANK PAG 1 3� (Two pages per tank) Page_of TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 4.AMENDED PERMIT �•5.CHANGE OF MFORMA11771OV1� ❑ 6.TEMPORARY TANK CLOSURE 430 C6eck ( one onto only) ❑ 3.RENEWAL PERMIT /v!W OWNC3eAh o ❑ 7.PERMANENTLY CLOSED ON SITE (Specify recon) (Specify reamn) ❑ B.TANK REMOVED BUSINES )ZISamn as FACILIT'NAMEOr DBA-Doing Business As) 3. FACILITY ID: I. F1ftc TRO Nc. o y �l LOCATION WITHIN SITE loanond) 431. 3Lio N Mar- �rltiuv Dr Tya cA 9537 1.TANK DESCRIPTION (A scaled plot plan with he location of the UST system including buildings and landmarks shall be submitted to the local a enc J TANK ID# 432. TANK MANUFACTURER 433. COMPARTMENTALIZED TANK ❑Yes ❑ No 434. EYES - If"Yes."-wjata one page 6r each moryenment. DATE INSTALLED 435- TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS 437. (YE O) 3hol2oo!r IQ.aoAfi4O ADDITIONAL DESCRIPTION(For local use only) us. II.TANK CONTENTS TANK USE 439. PETROLEUM TYPE 440. 1. MOTOR VEHICLE FUEL RI In. REGULAR UNLEADED p 2. LEADED ❑5. JET FUEL frJueked,mmglme Pmmkum Type) 9( MOTOR PREMIUM UNLEADED 03. DIESEL ❑6. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑le. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME (6oto Hamrdom Materiels Inventory pass) 44L CAS#(Rom Hazardous Materials m.mnory page) 442. ❑ 4. HAZARDOUS WASTE c oncludo Dud Oil) R�/�� U L ,p` PL ❑ 95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK ❑1. SINGLE WALL ❑3. SINGLE WALL WITH EXTERIOR ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. (Check one item only) MEMBRANE LINER 095. UNKNOWN DOUBLE WALL ❑4. SINGLE WALL IN A VAULT ❑99. OTHER TANK MATERIAL-primary tank I. BARE STEEL 3. FIBERGLASS/PLASTIC 05. CONCRETE ❑95.UNKNOWN 4" (Check one nem only) ❑2. STAINLESS STEEL 4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE [199.OTHER: REINFORCED PLASTIC FRP W/100%METHANOL ry TANK MATERIAL-secondatank 1. BARE STEEL 3. FIBERGLASS/PLASTIC0 8. FRP COMPTIBLE W/100%METHANOL Ll 95.UNKNOWN 015. (Check one item only) [12. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑9. FRP NON-CORRODABLE JACKET ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL [15. CONCRETE TANK INTERIOR LINING ❑1.RUBBER LINED 3.EPDXY LINING ❑5.GLASS LINING 0 95.UNKNOWN 446, DATE INSTALLED M7. OR COATING [12.ALKYD LINING [14.PHENOLIC LINING [16 UNLINED ❑99.OTHER Check one item onl OTHER CORROSION LI 1.MANUFACTURED CATHODIC 0 3.FIBERGLASS REINFORCED PLASTIC 95,UNKNOWN 448, DATE INSTALLED 449. PROTECTION PROTECTION ❑4.IMPRESSED CURRENT ❑99.OTHER If Gable 2.SACRIFICIAL ANODE SPILL AND OVERFILL YEARINSTALLED 450, TYPE 451. OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 452. (Check all that apply) N 1.SPILL CONTAINMENT 00 1.ALARM ❑3.FILL TUBE SHUT OFF VALVE 2.DROP TUBE .00 l 2.BALL FLOAT ❑4.EXEMPT 3.STRIKER PLAIII, IL%O • 00 IV.TANK LEAK DETECTION (Ade iption of the monitoring program shall be submitted to the local agency.) IF SINGLE WALL TANK 451 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454. (Check all that apply) (Chock ova item only) [11. VISUAL(EXPOSED PORTION ONLY) 5.MANUAL TANK GAUGING(MTG) ❑ I.VISUAL(SINGLE WALL IN VAULT ONLY) ❑2.AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE RJ 2.CONTINUOUS INTERSTITIAL MONITORING ❑3.CONTINUOUS ATG ❑7.GROUNDWATER ❑3.MANUAL MONITORING ❑4.STATISTICAL INVENTORY RECONCILIATION [18.TANK TESTING (SIR)+BIENNIAL TANK TESTING 099. 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 ❑Yea ❑ No UPCF hwfWm-b(1/99)-114 http://www.unidocs.org Rev.02/16/00