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D PROGRAM CONSOLIDATED FO q TANKS - yy'Al O 51109 b I UNDERGROUND STORAGE TANKS - TANK PAGE 1 7) 1-71A7 (Two pages per tank) Page_of TYPE OF ACTION 1.NEW PERMIT ❑ 4.AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6,TEMPORARY TANK CLOSURE 430. (Check one dem only) ❑ 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE (Specify rrseon) (Spmiry--) ❑ 8.TANK REMOVED BUSINSS NAME(Sameea FACILII'YNAMBor DBA-Ming Bminess ) 3. FACILITY ID: 1. l i LOCATION VIHIN SI (um..ap 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 a ency.) TANK ID# 432. TANK MANUFACTURER 435. COMPARTMENTALIZED TANK Yes El No 434. If"Yes,"eomplete one page for each compattmem DATE INSTALLED 435. TANKCAP CITY IN GALLON 436. NUMBER QF COMPARTMENTS ��IY` -'5 437. (YEAR/MO) ADDITIONAL DESCRIPTION(Far local use aaly) 436. II.TANK CONTENTS TANK,kSE 439' PETROLEUM TYPE 440, MOTOR VEHICLE FUEL ❑Is REGULAR UNLEADED ❑2. LF ED ❑5. JET FUEL (Ifchacked,complete Pelmleum Type) [3 lb. PREMIUM UNLEADED L,.d' 1FSEL ❑6. AVIATION GAS ❑ 2. NON-FUELPETROLEUM ❑le. MIDGRADE UNLEADED ❑4. GASOHOL 099.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME (from Hazardous Materials Inventory page) 441' CAS#(from Hazardous Materials Inventory page) 442. ❑ 4. HAZARDOUS WASTE (Includes Used Oil) ❑ 95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK [11. SINGLE WALL [13. SINGLE WALL WITH EXTERIOR ❑S. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. (Check one item only) MEMBRANE LINER ❑95. UNKNOWN . DOUBLE WALL ❑4. SINGLE WALL IN A VAULT [199. OTHER TANK MATERIAL-pnaaary tank LJ 1. BARE STEEL FIBERGLASS/PLASTIC ❑5. CONCRETE ❑95.UNKNOWN 444. (Check.item only) ❑2. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE ❑99.OTHER: ORCED PLASTIC FRP W/100%METHANOL TANK MATERIAL-secondary tank ❑1. BARE STEEL . FIBERGLASS/PLASTIC 08. PRP COMPTBLE W/ion.METHANOL 095.UNKNOWN 445. (Check one item only) [12. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS ❑9. FRP NON-CORRODABLE JACKET [199.OT14ER REINFORCED PLASTIC(PRP) ❑10. COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING ❑1.RUBBER LINED ❑3.EPDXY LINING [15.GLASS LINING [195.UNKNOWN 446, DATE INSTALLED 447. OR COATING ❑2.ALKYD LINING [14.PHENOLIC LINING ❑6.UNLINED [199.OTHER Check one item oN OTHER CORROSION ❑1.MANUFACTURED CATHODIC [13.FIBERGLASS REINFORCED PLASTIC ❑95.UNKNOWN 448. DATE INSTALLED 449. PROTECTION PROTECTION [14.IMPRESSED CURRENT [199.OTHER If Applicable) [12.SACRIFICIAL ANODE SPILL AND OVERFILL YEARMSTALLED 450, TYPE 451, OVERFILL PROTECTION EQUIPMENT: YEARINSTALLED 452. (Check all that apply) ❑I.SPILL CONTAINMENT ❑1.ALARM ❑3.FILL TUBE SHUT OFF VALVE ❑2.DROP TUBE ❑2.BALL FLOAT ❑4.EXEMPT ❑3.STRIKER PLATE IV.TANK LEAK DETECTION (A description of the monitoring program shall be submitted to the local agency.) IF SINGLE WALL TANK 453' IF DOUBLE WALL TANK OR TANK WITH BLADDER 454. (Check all that apply) (Check one 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 CONTINUOUS INTERSTITIAL MONITORING ❑3. CONTINUOUS ATG ❑7.GROUNDWATER ❑3.MANUAL MONITORING ❑4. STATISTICAL INVENTORY RECONCILIATION ❑S.TANK TESTING (SIR)+BIENNIAL TANK TESTING ❑99. OTHER V.TANK CLOSURE INFORMATION/ PERMANENT CLOSUREINPLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 455' ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456' TANK FJLLED WITH INERT MATERIAL? 457' gallons ❑Yes ❑ No UPCF hwfwrc-b(1/99)-1/4 www.unidocs.org Rev.02/16/00