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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UND&ROUND STORAGE TANKSWANK PAGE 1 (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 (Speciryreason-forkKaluseonly) (Specyroasco-arloaluseamy) ❑ STANK REMOVED 430 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 1 FACILITY ID: 1 Beacon Station#3698 LOCATION WITHIN SITE(optional) 431 I.TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local agency.) TANK ID# 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK [_]Yes ® No 434 3698-3 Modern 9 Yes',complete we page for each compartment. DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 438 NUMBER OF COMPARTMENTS 437 1/87 10152 1 ADDITIONAL DESCRIPTION(For local use only) 438 ll.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 ®1. MOTOR VEHICLE FUEL []la. REGULAR UNLEADED ❑2. LEADED [15. JET FUEL (If marked complete Petroleum Type) 01b. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION FUEL ❑2. NON-FUEL PETROLEUM ❑1c. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER ❑3. CHEMICAL PRODUCT COMMON NAME (fromHazardous Materialstmemory,page) 'N1 CAS#(from Hazardous Materials Inventory page) 442 ❑4. HAZARDOUS WASTE 8006-61-9 (includes Used oil ❑95.UNKNOWN Ill. 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 [195, UNKNOWN 12112. DOUBLE WALL [14. SIGNLE WALL IN VAULT ❑99. OTHER TANK MATERIAL-primary tank 01. BARE STEEL ❑3. FIBERGLASS/PLASTIC ❑5. CONCRETE ❑95. UNKNOWN 444 (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE W/ ❑99.OTHER REINFORCED PLASTIC(FRP) 100%METHANOL TANK MATERIAL-secandarytick 01. BARE STEEL ❑3. FIBERGLASS/PLASTIC ❑5. CONCRETE ❑95. UNKNOWN 445 (Check one item only) ❑2. STAINLESS STEEL ®4.STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE ❑99.OTHER REINFORCED PLASTIC(FRP) W1100%METHANOL [15. CONCRETE (:110.COATED STEEL TANK INTERIOR LINING ❑ 1.RUBBER LINED ❑3.EPDXY LINING ❑5.GLASS LINING ❑95.UNKNOWN bye DATE INSTALLED 447 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING ®6 UNLINED ❑99 OTHER (Check one item only) (Far local use only) OTHER CORROSION ❑ 1 MANUFACTURED CATHODIC❑3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN 448 DATE INSTALLED 449 PROTECTION IF APPLICABLE PROTECTION ❑4 IMPRESSED CURRENT ❑99 OTHER (Check ane item only) ❑2 SACRIFICIAL ANODE (Far local use only) SPILL AND OVERFILL YEAR INSTALLED 450 TYPE(local use orgy) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Check all ®1 SPILL CONTAINMENT Nat apply) 1/87 ®1 ALARM ❑3 FILL TUBE SHUT OFF VALVE ®2 DROP TUBE 1/87 ❑2 BALL FLOAT ❑4 EXEMPT ®3STRIKER PLATE 1/87 IV.TANK LEAK DETECTION(A description of me monitoring program shall be submitted to the kcal agency.) IF SINGLE WALL TANK(Check all mat apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 (Check we 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 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 I PERMANENT CLOSURE IN PLACE - ESTIMATED DATE LAST USED(YR/MO/DAY) 455 ESTIMATED QUANTITY OF SUBSTANCE 456 TANK FILLED WITH INERT MATERIAL? 457 REMAINING gallons ❑Yes ❑ No UPCF(1/99 revised) Formerly SWRCB Form B