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IFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 (two pages per tank) Pe'.777V TYPE OF ACTION ❑1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT IN 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (L'heck om imn only) ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT (Spedfynosom-forloceloseovly) (Specilyreeam-fmlomIseeonly) ❑ 8 TANK REMOVED 430 BUSINESS NAME(same as FACILITY NAME or onw-Doing Eueineae Aa) FACILITY ID: I IF Ti d d LOCATION THIN SITE(olni 631 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 encyJ TANK ID M 432 TANK MANUFACTURER 431 COMPARTMENTALIZED TANK ❑Yes o 434 0 Z �1i'it If"Yc ',woepine one rase fm emh wmpe.neem DATE MS ALLED(YEAR/MO) 435 TANK CAPACITY IN GALL S 436 NUMBER OF COMPARTMENTS 437 So Q Z, ? NA ADDITIONAL DESCRIPTION(For 1«el me only) 438 II.TANK CONTENTS TANK USE 434 PETROLEUM TYPE am JKL MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED ❑2. LEADED 05. JET FUEL pfmnkedcomplem PMnleom Type) ❑16. PREMIUM UNLEADED [93. DIESEL ❑6. AVIATION FUEL [12. NON-FUEL PETROLEUM ❑lc. MIDGRADE UNLEADED ❑4. GASOHOL [199.OTHER ❑3. CHEMICAL PRODUCT COMMON NAME (from Hwmdms Materials Inventory Page) 441 CASif(from 11--ni ua Materials Inventory page) 062 ❑4. HAZARDOUS WASTE 0.1a usmDiO ❑95.UNKNOWN III. TANK CONSTRUCTION TYPE OF TANK 0 I. SINGLE WALL 3. SINGLE WALL WITH U 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Chea one item only) EXTERIOR MEMBRANE LINER 095. UNKNOWN 1K2. DOUBLE WALL ❑4. SIGNLE WALL IN VAULT ❑99. OTHER TANK MATERIAL-pnray inn L1 I. BARE STEEL AL3. FIBERGLASS/PLASTIC Ll 5. CONCRETE 0 95. UNKNOWN 444 (Check one item Daly) [12. STAINLESS STEEL ❑4. STEEL CLAD W/FBERGLASS [18. FRP COMPTIBLE W/100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-xmnaar,mN 1. BARE STEEL JR3. FIBERGLASS/PLASTIC U 5. CONCRETE 95. UNKNOWN 445 (Ch Jr ave item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS [18, FRP COMPTIBLE W/100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10.COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING 0 1.RUBBER LINED Ll 3.EPDXY LINING 14 5.GLASS LINING 95.UNKNOWN 446 DATE INSTALLED 447 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING ❑6 UNLINED ❑99 OTHER (Chink Due Item only) (For Zonal me only) OTHER CORROSION ❑1 MANUFACTURED CATHODIC 93 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN as DATE INSTALLED 449 PROTECTION IF APPLICABLE PROTECTION ❑4IMPRESSED CURRENT ❑99 OTHER (Check om Iran only) ❑2 SACRIFICIAL ANODE (Fm local see only) SPILL AND OVERFILL YEAR INSTALLED 450 TYPE(locel see only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED /992_ 992- 452 (Checkallatapply) K I SPILL CONTAINMENT ❑1 ALARM JK Irl 2 DROP TUBE ❑2 BALL FLOAT ❑4 EXEMPT EN 3 STRIKER PLATE IV.TANK LEAK DETECTION(A dewriphon oftlte monimnng mvam awl x suhmi0edro on,local agemy.) IF SINGLE WALL TANK(cheek a111w apply) a53 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 (Chen me ltem only) ❑1 VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MTG) [I 1 VISUAL(SINGLE WALL IN VAULT ONLY) ❑2 AUTOMATIC TANK GAUGING(ATG) ❑6 VADOSE ZONE Iq2 CONTINUOUS INTERSTITIA.MONITORING ❑3 CONTINUOUS ATG ❑7 GROUNDWATER ❑3 MANUAL MONITORING ❑4 STATISTICAL INVENTORY RECONCILIATION ❑STANK TESTING (SIR) BIENNIAL TANK TESTING ❑99 OTHER IV.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 455 1 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 1 TANK FILLED WITH INERT MATERIA., 457 gallons ❑Yes ❑ No UPCF(12/99 revised) 10 Formerly SWRCB Form B