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�- bRIFIED PROGRAM CONSOLIDATED FOR 5)� ' � TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 1 (two pages per tank) u Pape _ of ❑ G.TEMPORARY SITE CLOSURE TYPE OF ACTION T-1.NEW SITE PERMIT ❑ 4.AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION) ❑ T PERMANENTLY CLOSED ON SITE (Check one item only) ❑3.RENEWAL PERMIT (S�,ry reason.forlocal uae only) (Speclfy change-.11.,use only) ❑ 8. TANK REMOVED 430 1 BUSINESS NAME(Same as FACILITY NAME or DBA /-JDoing Business As) FACILITY I I N y 11 %11,10,///fl LOCATION WITHIN SITE(Opbonar) 431 1.TANK DESCRIPTION TANK MANUFACTURER COMPARTMENTALIZED TANK L.y�res ❑ No TANK ID p If'Yes,complete one page f each compartment. NUMBER OF COMPARTMENTS DATE INSTALLED(YEARIMO) TANK CAPACITY IN GALLONS �ODv ADDITIONAL D SCRIPTION(Forlocal use only) II.TANK CONTENTS TANK USE 432 PETROLEUM TYPE ❑ 5.JET FUEL ` ❑1a. REGULAR UNLEADED ❑ 2. LEADED 1. MOTOR VEHICLE FUEL ❑ 8. AVIATION FUEL ( marked,complete PetD/eum Type) ❑Ib. PREMIUM UNLEADED 3. DIESEL [12. NON-FUEL PETROLEUM ❑ 4. GASOHOL [199. OTHER ❑1c. MIDGRADE UNLEADED C13. CHEMICAL PRODUCT CAS N(from Hazardous Materials Inventory page) COMMON NAME(from Hazardous Materials Inventory page) ❑ 4. HAZARDOUS WASTE(Includes Used Oil) III.TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM EXTERIOR MEMBRANE LINER ❑95. UNKNOWN (Check one item only) 2. DOUBLE WALL ❑ 4. SINGLE WALL IN A VAULT ❑99. OTHER TANK MATERIAL-primary lank la-1 BARE STEEL FIBERGLASS I PLASTIC ❑ 5. CONCRETE ❑95. UNKNOWN (Check one item only) `❑I`2. STAINLESS STEEL . STEEL CLAD WIFIBERGLASS ❑ B. FRP COMPATIBLE W1100%METHANOL ❑99. OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary tank ❑ 1 BARE STEEL 3. FIBERGLASS/PLASTIC ❑ 8. FRP COMPATIBLE WI100%METHANOL ❑95. UNKNOWN (Check one item only) ❑ 2. STAINLESS STEEL 4.STEEL CLAD WOBERGLASS ❑ 9. FRP NON-CORRODIBLE JACKET ❑99. OTHER REINFORCED PLASTIC(FRP) (310. COATED STEEL ❑ 5. CONCRETE DATE INSTALLED TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING ❑95. UNKNOWN433 OR COATING ❑ 4. PHENOLIC LINING �. UNLINED ❑99. OTHER For local use onl) ❑ 2. ALKYD LINING DATE INSTALLED (Check one item onl) OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC 3. FIBERGLASS REINFORCED PLASTIC 95. UNKNOWN 43a PROTECTION IF APPLICABLE PROTECTION 4. IMPRESSED CURRENT ❑99. OTHER (Forlocal use only) (Check one item only) ❑ 2. SACRIFICIAL ANODE OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED SPILL AND OVERFILL YEAR INSTALLED TYPE(For local use OnIA rr�V,� ZOO,?(Check all that apply) L' �1.ALARM (�L ❑ 3. FILL TUBE SHUT OFF VALVE ❑ 1. SPILL CONTAINMENT Z El2. DROP TUBE ooZ-- �� 6/ (&2. 13ALLFLOAT Ze�L❑ 4. EXEMPT ❑ 3. STRIKER PLATE Zoo Z �� IV.TANK LEAK DETECTION IF DOUBLE WALL TANK OR TANK WITH BLADDER Check one item only): IF SINGLE WALL TANK Check all that a ): ❑ 5. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALLIN VAULT ONLY) ❑ 1, VISUAL(EXPOSED PORTION ONLY) ❑ 6. VADOSE ZONE ❑ 2. CONTINUOUS INTERSTITIAL MONITORING ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ T GROUNDWATER C13. MANUAL MONITORING ❑ 3. CONTINUOUS ATG ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR)+ ❑ S. TANK TESTING BIENNIAL TANK TESTING ❑99. OTHER V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YRIMOIDAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL? gallons ❑Yes ❑No Formerly SWRCB Form B CUPAFORM(4/99)