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� w U D PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANKS -TANK pAGE 1 TANKS (two pages per tank) a. SITE PERMIT ❑ 4 AMENDED PERMIT 1 TYPE ACTION ❑1 NEW SPoge_,of_ (Check oro Ikm only) ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE ❑ 3 RENEWAL PERMIT •LBWOUCoSIANTEI$SC4 OC1C. {TrrxIWb(iSp`e1dEmeso -kronluw only), �: --- ❑ 7 PERMANENTLY CLOSED ON SITE AE(gaeaFACRIM (specify..a.-rd uonly) ❑ 8 TANK REMOVED -Dingu4J0 S M 3 WITHIN SITE(optional) -'$rr ,'ru3 �/ 431 I.TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildmgs and landmarks shall be submitted to the local agency,) I` TANK ID# a 43z TANK MANUFACTURER ��I �JCIOo�d 433 COMPARTMENTALIZEDTANK Yes ❑ No �A. 434 DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN G ONS u6 If"Ya wmpleta one page breach mmpamronr. 9 S' 3 t COMPARTMENTS coo NUMBER OF COMPA437 ADDITIONAL DESCRIPTION(For local me oNy) Z 438 TANK USE 439II,TANK CONTENTS PETROLEUM TYPE 1. MOTOR VEHICLE FUEL ❑In. REGULAR UNLEADED 440 (IrmukW eomplekPWokum Type) ❑2. LEADED ❑5. 7E7 FUEL ❑lb. PREMIUM UNLEADED 93. DIESEL ❑2 NON-FUEL PETROLEUM 130. AVIATION FUEL ❑lc. MIDGEADE UNLEADED ❑4. GASOHOL El 3. CHEMICAL PRODUCT ❑99.OTHER COMMON NAME (from Heallous Makdelslnrcnmry page) 441 -CA-S#-(f---Hemdous Mat .1.In, C]4.HAZARDOUS WASTE aCArypege) 442 (Include.Used Oil) 1195.UNKNOWN 7II. TANK CONSTRUCTION TYPE OF TANK 1. SINGLE WALL 3. SINC16 WALL WITH (Check ova item only) 5. SINGLE WALL Wl'CH INTERNAL BLADDER SYSTEM 443 y EXTERIOR MEMBRANE LINER 095.UNKNOWN Iq2. DOUBLE WALL ❑4. SIGNLE WALLIN VAULT' TANK MATERLII,- E)99. OTHER p^mart rerik - BARE STEEL I. FIBERGLASS/PLA$flG 5. CONCRETE (Checkmemmmly) Ll 2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS 95. UNKNOWN 444 ❑8. FRP COMPTIBLE W/100%METHANOL ❑99.OTBER REINFORCED PLASTIC(FRP) TANK MATERIAL-saondary tank 1. BARE STEEL J. FIBERGLASS/PLASTIC 5. CONCRETE 95.UNKNOWN m5 (Chak aro Item only) ❑2. STAINLESS STEEL 4, STEEI.CLAP W/FIBERGLASS '9 ❑8. FRP C LS W/I00%METHANOL 1199.OTHER REINFORCED PLASTIC(FRP) 13 I0.COATEDD MEL ❑5. CONCRETE TANK INTERIOR LUNIING jLRUBBER LINED 3.EPDXY LINING S.GLASS LINNG 95.UNKNOWN 446 DA'TEINSTALLED 447 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING(Clxdr oroitem oNy) ❑6 UNLINED ❑99 OTHER (Parlonl use only) OTHER CORROSION ❑1 MANUFACTURED CATHODIC ❑3 FIBERGLASS REINFORCED PLASTIC448 DATE INSTALLED 449 PROTECTION IF APPLICABLE PROTECTION ❑95 UNKNOWN (Clack one lam only) ❑2 SACRIFICIAL ANODE ❑4 IMPRESSED CURRENT ❑99 OTHER SPILL AND OVERFILL YEAR INSTALLED / 450 (Por local use oNy) (CheckalltlmtaCONTAINMENT ) TYPE(local use only) 451 OVERFILL PROTECCION EQUIPMENT:YEAR INSTALLED fS- 452 PPIY) 1 SPILL CONTAAIMBNT ®2 DROP TUBE ❑1 ALARM LS 3 FILL TUBE SHUT OFF VALVE �3 STRIKER PLATE ❑2 BALLFLOAT 94 EXEMPT IV.TANK LEAK DETECTION(A desmiption ortM modroring pro IF SINGLE WALL TANK(Check alltlneappty) Bro^.hell be mb ---the--egaro-- 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 ❑1 VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING (check om item only) El AUTOMATIC TANK GAUGING(ATG) O'STG) ❑I VISUAL(SINGLE WALL IN VAULT ONLY) ❑6 VADOSE ZONE 2 CONTINUOUS INTERSTITIAL MONITORING ❑3 CONTINUOUS ATG ❑7 GROUNDWATER ❑4 STATISTICAL INVENTORY RECONCILIATION 8 TANK TESTING ❑3 MANUAL MONITORING (SIR) BIENNIAL TANK TESTING ❑99 OTHER i..TAN Mn$L>gE INFORMATION/PERfiANENT CivosJRE,TN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 'TANK FILLED r cD W(TH B4ERT MATERIAL? 457 gallons ❑Yes ❑ No UPCF(12/99 revised) 10 Formerly SWRCB Form B