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Y - L IFIED PROGRAM CONSOLIDATED FO TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 _ (two pages per tank) Page of 1_ TYPE OF ACTION ❑1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT X 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (LTak one item only) ❑ 7 PERMANENTLY CLOSED ON SITE 3 RENEWAL PERMIT (Spaifyoermo-forbcalusemnly) (Spai4mirrion-forlrcsluxonly) ❑ 8 TANK REMOVED 430 BUSINESS NAME(Same a a FACILITY NAME or DBA-Don,Business Ar) FACILITY ID: 1 �•gS T it 3 c3 LOCATION WITHINSITE< p0omp Z�'Ij (..in So- - 431 L TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local agency.) 'TANK ;'( 432 TANK MANUFACTURER 4y3 COMPARTMENTALIZED TANK ❑Yes o 4M DIY/lJr lie If"Yea",complete one page 6r och compmiment. DATE SST LL D(YEAR/MO) -5 TANK C PACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 61 O/Vz f/ vBo aCluzs •U.4 ADDITIONAL DESCRIPTION(For local use only) 438 EL TANK CONTENTS TANK USE 439 PETROLEUM TYPE aa0 ❑1. MOTOR VEHICLE FUEL ❑In. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (Rmarkd complete eatrolamn Type) ❑Ib. PREMIUM UNLEADED 03. DIESEL ❑6. AVIATION TFUEL NON-FUEL PETROLEUM ❑In. MIDGRADE UNLEADED 04. GASOHOL [gq9.OTHER ❑3. CHEMICAL PRODUCT COMMON NAME (from Havrdoas miarmn s Imedory page) 441 CAS#(Item Rmordous Materials Inventory page) 441 [14, HAZARDOUS WASTE � (Include Used O8) /Y'G,trtai++rs,5'io�I FLu/d G',e}5' 6Y742-6.sv ❑95.UNKNOWN III. TANK CONSTRUCTION TYPE OF TANK 1. SINGLE WALL 3. SINGLE WALL WITH Ll 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Okel,one item only) EXTERIOR MEMBRANE LINER ❑95. UNKNOWN W. DOUBLE WALL [14. SIGNLE WALL IN VAULT ❑99. OTHER TANK MATERIAL-primary urdr 0 1. BARE STEEL 993. FIBERGLASS/PLASTIC El 5. CONCRETE 0 95. UNKNOWN 444 ((Ieck ok item only) [12. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPTIBLE W/100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) TANK MATERW.-smondory tank 171. BARE STEEL K3. FIBERGLASS/PLASTIC El 5. CONCRETE 0 95. UNKNOWN 445 (Chat one item orsly) ❑2. STAINLESS STEEL []4, STEEL CLAD W/FISERGLASS [38, FRP COMPTIBLE W/l WK METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10.COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING 1.RUBBER LINED L1 3.EPDXY LINING .GLASS LINING 95.UNKNOWN 445 DATE INSTALLED 447 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING ❑6 UNLINED ❑99 OTHER (Chat ome item only) (Fa bead useonly) OTHER CORROSION ❑1 MANUFACTURED CATHODIC Q)13 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN 448 DATE INSTALLED 449 PROTECTION IF APPLICABLE PROTECTION ❑4IMPRESSED CURRENT ❑99 OTHER (cnak one item only) ❑2 SACRIFICIAL ANODE (Fa local use ody) SPILL AND OVERFILL YEAR INSTALLED 450 TYPE(localurcooly) 451 OVERFILL PROTECTION EQUIPMENTNEAR INSTALLED99 Z 452 (Check all that ap pply) yI SPILL CONTAINMENT ❑1 ALARM Eb FILL TUBE SHUT OFF VALVE Caspy 2 DROP TUBE ❑2 BALL FLOAT ❑4 EXEMPT Ig 3 STRIKER PLATE IV.TANK LEAK DETECTION(A&wrigbn eflhe mmnlbring pregam shall be,susmimed to the local agency.) IF SINGLE WALL TANK(chat an wt apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 (Check one item oNy) ❑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 EL;CONTINUOUS mmss;T T At,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) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 gallons ❑Yes ❑ No UPCF(12/99 revised) 10 Formerly SWRCB Folin B