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NIFIED PROGRAM CONSOLIDATED FOA!R'r <br /> TANKS <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 1 <br /> �• (Mb pages per tank) <br /> T O 1 J Page _ of <br /> TYPEOFACTION 0 I.NEW SITE PERMIT 0 4.AMENDED PERMIT �5. CHANGE OF INFORMATION) 0 5. TEMPORARY SITE CLOSURE <br /> (CMck ons i4m Dory) ].RENEWAL PERMIT 0 ?. PERMANENTLY CLOSED ON SITE <br /> cdY <br /> ❑ (SPanamn-lorbcalu»orky) (Spedryr ame-lorb al use arvy) ❑ a. TANK REMOVED 430 <br /> BUSINESS NAME(Same as FACILITY NAME wnDBA-Doing Business As) FACILITY ID N ';A i t <br /> 1 <br /> LOCA ON NATHIN SITE 6]1 <br /> i5 S u 95L�o <br /> 1.TANK DESCRIPTION <br /> TANK IDY 2 TANK MANUFACTURE <br /> tJ COMPARTMENTALIZED TANK ❑ Yee No <br /> IYY.",..Plate ana peps br eaCl cpm uMa t. <br /> DATE INSTALLED <br /> D((YEAARRMO)J TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> a4l.A/ <br /> ADDITIONAL DESCRIPTION(Forbcal ass Only) <br /> 11.TANK CONTENTS <br /> TANK USE 432 PETROLEUM TYPE <br /> �I 1. MOTOR VEHICLE FUEL 13 1., REGULAR UNLEADED LEADED ❑ 5. JET FUEL <br /> (R rr�a�l MeC,compete PefroNum Typ) <br /> 11 Is PREMIUM UNLEADED ,❑ 3. DIESEL ❑ B_ AVIATIONFUEL <br /> 0 2. NON-FUELPETROLEUM 111. MIDGRADE UNLEADED ❑ 4. GASOHOL 00 OTHER <br /> ❑ 3. CHEMICALPRODUCT <br /> ❑4.HAZARDOUS WASTE(Iwsahas COMMON"ME(slams HasarEpus Mafeaale lnnnbrypage) CAS N Rmm Haautlpua MMaRaM lnwnlery Pa9e) <br /> Ute4 Od) <br /> 0 95 UNKNOWN <br /> 111.TANK CONSTRUCTION <br /> TYPE OF TANK SINGLE WALL 0 3. SINGLE WALLYATH 0 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> (CMck wro dem Dory) 02. DOUBLE WALL EXTERIOR MEMBRANE LINER 095. UNKNOWN <br /> - 0 9. SINGLE WALL IN A VAULT 099 OTHER <br /> TANK MATERIAL.waeary tank 'Isar BARE STEEL ❑ 3. FIBERGLASS I PLASTIC 0 5, CONCRETE 095. UNKNOWN <br /> (Clwaneck oMm wy) !�❑ 2. STAINLESS STEEL 0 A. STEELCLADW/FIBERGLASS 0 e. FRP COMPATIBLE WlIW%METHANOL 099. OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-eacwgary lank X,, BARE STEEL 133. FIBERGLASS I PLASTIC ❑ 9. FRP COMPATIBLE W/10D%METHANOL ❑95. UNKNOWN <br /> (Check em iNm Dray) �❑ 2. STAINLESS STEEL 0 a. STEEL CLAD VeXiBERGLASS 0 9. FRP NON-0ORRODIBLE JACKET 099. OTHER <br /> REINFORCED PLASTIC(FRP) 0 10. COATED STEEL <br /> 0 S. CONCRETE <br /> TANK INTERIOR LINING 0 1, RUBBER LINED 0 3. EPDXY LINING ❑ 5. GLASS LINING 095. UNKNOk I433 DATEINSTALLEO <br /> ORCOATING <br /> ❑ 2. ALKYD LINING ❑ 0. PHENOLIC LINING UNLINED 099.OTHER Fwlxaluseo ) <br /> Mck orr dem on ) <br /> OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC 095. UNKNOWN 434 <br /> DATE INSTALLED <br /> PROTECTION IF APPLICABLE PROTECTION A�p�- ,, <br /> ❑ a. IMPRESS ED CURRENT 99. OTHERA(LJO_L� (Fwbcalu..MY) <br /> lCMck aM dam onM 0 2. SACRIFICIAL ANODE <br /> SPILL AND OVERFILL YEAR INSTALLED TYPE(Fo/bcal use 0*) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (CMckaYMatapPM 0 1 SPILL CONTAINMENT 0 1.ALARM 0 3. FILL TUBE SHUT OFF VALVE <br /> 0 2. OROPTUBE 0 2. BALL FLOAT 0 4. EXEMPT <br /> 0 3. STRIKER PLATE <br /> 'N:TANK LEAK DETECTOR <br /> IF SINGLE WALL TANK CMG as Mata IF DOUBLE WALL TANK OR TANK WITH BLADDER CMck orw dem <br /> ❑ 1, VISUAL(EXPOSED PORTION ONLY) 0 S. MANUAL TANK GAUGING INTO) 0 1. VISUAL(SINGLE WALL IN VAULT ONLY) <br /> 0 2. AUTOMATIC TANK GAUGING(ATG) 0 B. VADOSEZONE 0 2. CONTINUOUS INTERSTITIALMONITORING <br /> 0 3. CONTINUCUSATG 07, GROUNDWATER 0 3. MANUALMONRORING <br /> 04. STATISTICAL INVENTORY RECONCILIATION(SIR) 9. TANK TESTING <br /> BIENNIAL TANKTESTING OTHER <br /> V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USEDlYR/MCfDAYi ESTIMATED QUANTITY OF SUBSTANC INING 435 TANK FILLED WITH INERT MATERIAL? <br /> gas.. <br /> MAR 2 S 2001 � o( <br /> ENVIRONMENT HEALTH Form"SWRCB Form B <br /> CUPAFORM(4199) %111110, .,,iERMIT/SERVICES <br />