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UNIVPPROGRAM CONSOLIDATED PORM UNDERGROUND STORAGE TANKS -TANK pAGE 1 TANKS (two pages per tank) TYPE OF ACTION ❑ Ja NEW SITE PERMIT [:14 AMENDED PERMIT Page_of_ (Check ons item only) ❑ 5 CHANGE OF MFORMATION ❑ 6 TEMPORARY SITE CLOSURE �\ ❑ 3 RENEWAL PERMIT ❑ 7 PERMANENTLY CLOSED ON SITE (SpecIly recon-t'orlocalweonly) (SPcefy man-furloal can only) ❑ 8 TANK REMOVED 'BUSINESS NAME(Samoss PpLTLrIY NAME or DHA-Doing Ininess ps) FACILITY ID: ,c,;, 430 "Aft dl i CGY O yI 3 It7t WO F!.: stip LOCATI WITHIN SICcTE(opaonap .• .', J > 431 '(J� I.TANK DESCRIPTION (A scaled plot n with the location of the UST system including buildings and landmarks shall be submitted to the local agency.) TANK ID# 43z TANK MANUFACTURER D��5 / 433 COMPARTMENTALIZED TANK Yes ❑ No 434 3 �°'" DATE INSTALLED(YEAR/MO) 435 I &CAPLONS � 436 3f'YeY'wmplek one page foreah mmpemnel. 4NUMBER OF COMPARTMENTS 437 ADDITIONAL DESCRIPTION(Par local ma only) 00� Z 438 II.TANK CONTENTS TANK USE 439 PETROLEUM TYPE ILL MOTOR VEHICLE FUEL I- REGULAR UNLEADED4a0 (If marked complete Pa"kna Type) ❑3. LEADED ❑5. JET FUEL ❑Ib. PREMIUM UNLEADED [13. DIESEL El 2 CHEMIC ❑ El 6. AVIATION FUEL AL PETROLEUM Ic MIDGRADE UNLEADED ❑4. GASOHOL ❑3. CHEMICAL PRODUCT 1199.OTEI�R ❑4. HAZARDOUS WASTE COMMONNAM$ (from Hv"rdoua Materielalnvabry page) 441 CAS#(aomHanrdom Ma4riaklhvmwrypage) 442 (Indudas Usad Oil) ❑95.UNKNOWN III. TANK CONSTRUCTION TYPE OFTANK 1. SINGLE WALL 3. SINGLE WALL WITH S. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check orc item only) EXTERIOR MEMBRANE LINER ❑95. UNKNOWN 2. DOUBLE WALL ❑4. S[GNLE WALL IN VAULT ❑gg, OTHER TANK MATERIAL_Primyy mNc il). HARE STEEL1715. FIBERGLASS/PLAST95. UNKNOWN 444 IC 5. CONCRETE (Cheakow item only) [12. STAINLESS STEEL [14. STEEL CLAD W/FMERGLASS ❑8. FRP COMPTIBLE W/100°/,METHANOL [199.OTHER REINFORCED PLASTIC(PRP) TANK MATERIAL-remmhty look 1. BARE STEEL 3. FIBERGLASS/PLASTIC S. CONCRETE 95.UNKNOWN 445 (Check orc item only) ❑2 STAINLESS STEEL Iq4. STEEL CLAD W/FIBERGLASS 'Y [38- FRP COMPTTBLE W/l00%METHANOL ❑99.OITIER REINFORCED PLASTIC(FRP) ❑10.COATED STEEL 115. CONCRETE TANK INTERIOR LINING 1.RUBBflR LINED 3.EPDXY LI1 5.GLASS LINING 95.UNKNOWN 445 DATE INSTALLED 497 OR COATING 112 ALKYD LINING ❑4 PHENOLIC LINING (Check am item oay) ❑6 UNLINED ❑99 OTHER (For-IIOTHER CORROSION ❑I MANUFACTURED CATHODIC ❑3 FIBERGLASS REINFORCED PLASTIC448 DATE INSTALLED 449 PROTECTION IF APPLICABLE PROTECTION ❑95 UNKNOWN (Check am Item onl Y) ❑2 SACRIFICIAL ANODE ❑41MPRESSED CURRENT 1199 OTHER SPILL AND OVERFILL YEAR INSTALLED p 450 (For local use only) (Checkallthel I II TYPElialoaeonly) 451 OVERFILL PROTECTION EQUIPMENr;YEAR INSTALLED 452 appy) �QISPILLCONTAINMENT 9r ®2 DROP TUBE ❑1 ALARM 3 FILL TUBE SHUT OFF VALVE I�3 STRIKER PLATE ❑2 BALL FLOAT ❑4 MPT PXR IV.TANK LEAK DETECTION(A description ofthe maNmring pmgmm atoll be submitted to the local agency.) IF SINGLE WALL TANK(cneaken that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 1:11 VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING {.C., item only) - ❑2 AUTOMATIC TANK GAUGING(ATGCr) l-1 I VISUAL(SINGLE WALL IN VAULT ONLY) ❑6 VADOSE ZONE El 3 CONTINUOUS ATG 2 CONTINUOUS INTERSTITIAL MONITORING ❑7 GROUNDWATER ❑3 MANUAL MONITORING ❑4 STATISTICAL INVENTORY RECONCILIATION ❑8 TANK TESTING (SIR) BIENNIAL TANK TESTING 1199 OTHER TV.TAN Y CLOSURE INFORMATION!PERT.IANE NICL O"o'4IRE iN PLACE ESTIMATED DATE LAST USED(YRMMO/DAY) 433 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 41' gallons ❑Yes ❑ No UPCF(12/99 revised) 10 Formerly SWRCB Form B