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r + . p UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 1 Tank #I (Two pages per tank) TYPE OF ACTION $I 1.NEW PERMIT PageofZ ❑ 4.AMENDED PERMIT ❑ 5.CHANGE OFNFORMATION ❑ 6.TEMPORARY TANK CLOSURE a3a. (Check..nem only) ❑ 3.RENEWAL PERM IT ❑ 7.PERMANENTLY CLOSED ON SITE (Specifyrtnan) (Spl all ❑ 8.TANK REMOVED BU$INE$SNAME(Santa os FACILITY NAMEor DBq-ppinB Bsiners As)a3. FACILITY ID: Rancho San Miguel Market LOCATION WITHIN SITE(Optional) 431. I.TANK DESCRIPTION (A scaled lot lan with the location of the UST System including buildings and landmarks shall be submitted to[helm .) TANK ID H 432. TANK MANUFACTURER 433. al agent K6T Steel T 0515 COMPARTMENTALIZED TANK ®Yes ❑ No 434 DATE INSTALLED 435. If"vas,"complete one page for each compartment, (YEAR/MO) TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS 7/24/03 20,000 437. ADDITIONAL DESCRIPTION(For mcal use only) 438. II.TANK CONTENTS TANK USE 439. PETROLEUM TYPE Ct L MOTOR VEHICLE Ft1EL 9la. REGULAR UNLEADED 440. he (Ifccked,complete Pmmle en Type) ❑2. LEADED ❑5. JET FUEL ❑Ib. PREMIUM UNLEADED ❑3. DIESEL El 6. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑Ic. MIDGRADE UNLEADED ❑4, GASOHOL ❑99.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME Ifmm Hazardous Mmaritls 441 Imam. ❑ 4. HAZARDOUS WASTE O'Paee) . CASK frrom Hemrdoua Meteriah lnwmaO'PaBe) 442. (Includes Deed Oil) ❑ 95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK ❑I. SINGLE WALL ❑3. SINGLE WALL WITH EXTERIOR (Check one item only) MEMBRANE LINEA ❑95.5 NGKNOWNLL WITH INTERNAL BLADDER SYSTEM 443. TANK MATERIAL-primary link ISI. BORE 3TEEIA,LL ❑4, SINGLE WALLNAVAULT ❑99, OTHER ❑3. FIREAGLASS/PLASTIC ❑5. CONCRETE 95.UNKNOWN (Check one nem only) ❑2. STAINLESS STEEL ❑4, STEEL CLAD W/FIBERGLASS444. ❑8. FRP COMPATIBLG ❑99.OTHER: REINFORCED PLASTIC FAP W1100°h METHANOL TANK MATERIAL-secondary tank ❑I. BpAE STEEL 3. FIBERGLASS/PLASTIC ❑8. FRP COMPTIBLE W/100%METHANOL 95.UNKNOWN 445. (Check one item only) ❑2. STANLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑9, FRP NON- REINFORCED PLASTIC FRP CORRODABLE IACI:ET 1199.OTHER ❑5. CONCRETE ( ) ❑10. COATED STEEL TANK INTERIOR LINING ❑L RUBBER LVED ❑3.EPDXY LNNG ❑,, GLASS LINING OR COATING ❑2.ALKYD LINING ❑4.PHENOLIC LNNG ®6.UNLINED ❑95.UNKNOWN 446. DATE INSTALLED 44). Check one inerrant ❑99.OTHER OTHERCORROSION ❑ I.MANUFACTURED CATHODIC 3.FlBERGLAS 1 REINFORCED PLASTIC ❑95.UNKNOWN 448. DATE INSTALLED 449, PROTECTION PROTECTION ❑4.IMPRESSED CURRENT HI'Appli02.SACRIFICIAL ANODE 1399.OTHER SPILL AND OVERFILL YFAR NSTALLED 450. 451. OVERFILL PROTECTION E UIPMENT: YEAR NSTALLED (C heck all that apply) ®].SPILL CONTAINMENT 2003 q8i� 2.DROP TUBE -�'�3' Ell.ALARM 3.FILL TUBE SHUT OFF VALVE201/S 3.STRIKER PLATE [12.BALL FLOAT_ ❑4,EXEMPT IV.TANK LEAK DETECTION IF SINGLE WATANK (A description of the monitoring program Shall be submitted to the local agency.) LL 453, IF DOUBLE WALL TANK OR TANK WITH BLADDER 454. (Check all that eDPIY) ❑1. VISUAL(EXPOSED PORTION ONLY) ❑5.MANUAL TANK GAUGING MTG (Check one item only) ( ) ❑1.VISUAL(SNGLE WALL IN VAULT ONLY) ❑2.AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE 1f]2,CONTINUOUS INTERSTITIAL MONITORING ❑3.CONTINUOUS ATG ❑7.GROUNDWATER [13.MANUAL MONITORING ❑4. STATISTICAL INVENTORY RECONCILIATION El S.TANK TESTING (SIR)�BIENNIAL TANK TESTING 099. OTHER V.TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USE D(YR/MO/DAY) 455. ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456. TANK FILLED WITH INERT MATERIAL? 457. gallons ❑Yes ❑ No UPCF hwfwrc-6(1/99)-1/4 http://Www.unidocs.org Rev.02/16/00