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xJ NIFIED PROGRAM CONSOLIDATED FOR:... D~ <br /> ANFt <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 ``(� <br /> (ho pages p r <br /> Page _ of _ <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 4. AMENDED PERMIT C 5, CHANGE OF INFORMATION) ❑ 6. TEMPORARY SITE CLOSURE <br /> (Check Ons item only) ❑ T. PERMANENTLY CLOSED ON SITE <br /> ❑].RENEWAL PERMIT ISpksyrasaon-e I-IIIuasooly) (Speolly ceerps-arlocal use only) ❑ 8. TANK REMOVED 430 <br /> BUSINESS-NAME(Sam.as FACILITY NAME of DBA-Doing Businefs As) FACILITY IDN - 1 <br /> LOCATION HIN SITE p eneq 101 <br /> I.TANK DESCRIPTION <br /> TANK IDN TANK MANUFACTURER COMPARTMENTALIZED TANK ❑ Yef IX No <br /> II'Yei,wmplNe one page for each compartment. <br /> Tank 111 <br /> DATE INS TALLED(YEAN/MO) TANK 693A-C'4 IN GALLONS NUMBER OF COMPARTMENTS <br /> ADDITIONAL DESCRIPTION(Fo/Iccal u»only) <br /> II.TANK CONTENTS <br /> TANK USE 432 PETROLEUM TYPE ❑ 5 JET FUEL <br /> ❑ 1 MOTOR VEHICLE FUEL ❑1a REGULAR UNLEADED ❑ 2. LEADED <br /> (lmadsd.compare Petroleum Type) ❑1E. PREMIUM UNLEADED ❑ ]. DIESEL M 5. AVIATION FUEL <br /> ❑ 2. NON-FUEL PETROLEUM ❑1c MIDGRADEUNLEADED ❑ 4. GASOHOL ❑N OTHER <br /> ❑ ]. CHEMICALPRODUCT GOMMONNAMEffmm HazaAOus Maaeslalnwnhory Page) CAS'pmm Hazardous MaAm-Ialnvenarypape) <br /> ❑ 4. HAZARDOUS WASTE(Inct lea <br /> Went 0,19 <br /> 95 UNKN�- <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1. SINGLE WALL ❑ ]. SINGLE WALL WITH ❑ S. SINGLE WALL W1TM INTERNAL BLADDER SYSTEM <br /> R.{T EXTERIOR MEMBRANE LINER 095. UNKNOWN <br /> (Check one item omy) LJ 2. DOUBLE WALL ❑ 4. SINGLE WALL IN A VAULT <br /> fie ❑99. OTHER <br /> TANK MATERIAL-primary lank ❑ 1 BARE STEEL 4[]. FIBERGLASS I PLASTIC ❑ 5. CONCRETE ❑95. UNKNOWN <br /> (WacMem item ony) ❑ 2. STAINLESS STEEL X1 3. <br /> STEEL CUD REINFORCED PIIASERGILATIC P ❑ a. FRP COMPATIBLE W1100%METHANOL N. OTHER <br /> TANK MATERIAL-asconocaY Mnk ❑ 1 BARE STEEL y+ ]. FISERGIASS I PLASTIC ❑ 8. FRP COMPATIBLE WIIOO%METHANOL ❑95. UNKNOWN <br /> fOhackonslamony) ❑ 2. STAINLESS STEEL ❑ 4 STEEL CUD REINFORCED PLASTIC(FRP) ❑ 9. FRP NON-CORRODIBLE JACKET ❑99. OTHER <br /> ❑10. COATED STEEL <br /> ❑ 5. CONCRETE <br /> DATEINSTALIED <br /> TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑ ]. EPDXYLINING ❑ 5. GLASS LINING ❑95. UNKNOWNA] <br /> OR COATING <br /> ❑ 2. ALKYO LINING ❑ 4. PHENOLIC LINING ❑ 6 UNLINED N. OTHER (Fo/Imal use onl) <br /> Lneck one item onl) DATE INSTALLED <br /> OTHERCORROSION ❑ L MANUFACTURED CATHODIC ❑ ]. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN 4]4 <br /> PROTECTION IF APPLICABLE PROTECTION <br /> ❑ 4. IMPRESSED CURRENT 99. OTHER (Fo/local vas only) <br /> (LhILkOM item omy) ❑ 2. SACRIFICIALANODE <br /> SPILL AND OVERFILL YEAR INSTALLED TYPE(Forlocal use Doty) OVERFILL PROTECTION EDUIPMENT'.YEAR INSTALLED <br /> (Check aN heal appy) ❑ 1. SPILL CONTAINMENT ❑ 1. ALARM ❑ ]. FILL TUBE SHUT OFF VALVE <br /> ❑ 2. DROP TUBE ❑ 2. BALLFLOAT ❑ 4. EXEMPT <br /> ❑ ]. STRIKER PLATE <br /> - N.TANK LEAN DETECTION <br /> IF DOUBLE WALL TANKORTANN WITH BUDOER'CM1eckom ihem on ): <br /> IF SINGLE WALL TANK Check a8 hM1af a <br /> ❑ 1, VISUAL(E%POSEDPORTION ONLY) ❑ S. MANUAL TANK GAUGING(MTG) lb 2. <br /> VISUAL(SINGLE WALLIN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ 8. VAGOSEZONE 4J 2. CONTINUOUS INTERSTITIAL MONITORING <br /> ❑ ]. CONTINUOUSATG ❑ 2. GROUNDWATER ❑ ]. MANUAL MONITORING <br /> ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR) ❑ S. TANKTESTING <br /> BIENNIAL TANK TESTING 0 9, OTHER <br /> V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESDMATEO DATE LAST USED(YRs1MOIDAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL? <br /> gallons ❑Yef ❑No <br /> Formerly SWRCB Form B <br /> CUPAFORM(4/99) <br />