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IFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 1 (two pages per tank) Pose of t TYPE OF ACTION ❑1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT Ca 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Check one iter only) ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT (Speciryreason-forlocetneeonly) (Speciryrtuon-falocelmeonly) ❑ 8 TANKREMOVED 439 BUSINESS NAME(Same n FACILITY NAME or DBA-Doing uneinees Aa) FACILITY ID: 1 : fidc)f✓4 ' LOCATION VOKIIIN SITE(opnonap 491 1.TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted w the local agency.) TANK ID# 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK ❑Yes o 430 �3 - o3B r o Q4(7( f L_(/�nfn If"Yn".complete cone page for nobcompertlnant DATE INSLT 1LLE/p(YEAR/MO) 435 TANK CAPACITY IN GALLOM 436 NUMBER OF COMPARTMENTS 437 1157/ro/4Z 1 ZD 000 p��S /V,4ADDITIONAL DESCRIPTION(For low me city) 438 II.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 4a MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED s❑�2'. LEADED 05. JET FUEL (Ifnur4cd le careplethrolnm Type) ❑lb. PREMIUM UNLEADED W. DIESEL ❑6. AVIATION FUEL ❑2. NON-FUEL PETROLEUM ❑In. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER 03. CHEMICAL PRODUCT COMMON NAME (from Ha.:rdons Mmenale Inventory page) 441 CAS#(6om Hancoinoa Melenals Inventory Ease) "2 ❑4. HAZARDOUS WASTE ( USW )❑95.UNKNOWNMesen f"u el t"14V 1*6jx�76 -34-(o III. TANK CONSTRUCTION TYPE OF TANK U 1. SINGLE WALL Ll 3. SINGLE WALL WITH 115. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one Bern only) EXTERIOR MEMBRANE LINER ❑95. UNKNOWN 192. DOUBLE WALL [14. SIGNLE WALL IN VAULT ❑99. OTHER TANK MATERIALL-Prtmary bank U 1. BARE STEEL 3. FIBERGLASS/PLASTIC 0 5. CONCRETE 95. UNKNOWN 444 (Check one item only) ❑2. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPTIBLE W/100%METHANOL [199.OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary back Ll 1. BARE STEEL K3. FIBERGLASS/PLASTIC 0 5. CONCRETE U 95. UNKNOWN 445 (check am item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPTIBLE W/100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10.COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING 1.RUBBER LINED ❑3.EPDXY LINING K5.GLASS LINING 95.UNKNOWN a46 DATE INSTALLED 447 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING ❑6 UNLINED ❑99 OTHER (Check meri4m only) (Fm local me only) OTHER CORROSION ❑1 MANUFACTURED CATHODIC C93 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN 448 DATE INSTALLED 449 PROTECTION IF APPLICABLE PROTECTION ❑4IMPRESSED CURRENT ❑99 OTHER (cheer one hem onlr) ❑2 SACRIFICIAL ANODE (For Inca use only) SPILL AND OVERFILL YEARINSTALLED 4% TYPE(locaauonly) 451 OVERFILL PROTECTION EQUIPMENTNEAR INSTALLED/rtq 2. 452 (check all that apply) I SPILL CONTAINMENT ❑1 ALARM Q3 FILL TUBE SHUT OFF VALVE 2 DROP TUBE ❑2 BALL FLOAT ❑4 EXEMPT Qg 3 STRIKER PLATE IV.TANK LEAK DETECTION(A donniptim ofine moniwnng program shall be eabenimd to the Iota agency.) IF SINGLE WALL TANK(check all that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 (Check can bent only) ❑1 VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MTG) ❑l VISUAL(SINGLE WALL IN VAULT ONLY) ❑2 AUTOMATIC TANK GAUGING(ATG) ❑6 VADOSE ZONE PL2 CONTINUOUS INTERSTITIAL MONITORING ❑3 CONTINUOUS ATG ❑7 GROUNDWATER ❑3 MANUAL MONITORING ❑4 STATISTICAL INVENTORY RECONCILIATION ❑8 TANK TESTING (SIR) BIENNIAL TANK TESTING ❑99 OTHER IV.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) a55 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 gallons ❑Yes ❑ No UPCF(12/99 revised) 10 Formerly SWRCB Form B