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IED PROGRAM CONSOLIDATED FOR <br /> TANKS <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 1 <br /> (two pages per tank) <br /> Page _ of <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 4. AMENDED PERMIT A 5. CHANGE OF INFORMATION) ❑ 8. TEMPORARY SITE CLOSURE I G <br /> (Check one item only) ❑ 7. PERMANENTLY CLOSED ON SITE LJ <br /> ❑3.RENEWAL PERMIT (Specify reason-for local use only) (Specify change•for local use only) ❑ 8. TANK REMOVED 430 <br /> B <br /> NESSSBme as FACILITY NAME or DBA• ing Business As) . FACILITY ID#r 1Cf, <br /> LOCATSITE(OptionaQ 4Jt <br /> I.TANK DESCRIPTION <br /> TANK 10# TANK MANUFACTURE COMPARTMENTALIZED TANK C1 Yes ❑ No <br /> i//1 n If'Yes',complete one page for each compartment. <br /> DATE INSTALLED(Y,EAR/MO) TANK CAPACI IN GALLONS�1/ NUMBER OF COMPARTMENTS <br /> 01 Jv` <br /> ADDITIONAL DESCRIPTION(For local use only) <br /> 11.TANK CONTENTS <br /> TANK USE 432 PETROLEUM TYPE <br /> ❑ 1 MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED ❑ 2. LEADED ❑ 5 JET FUEL <br /> (If marked,complete Petroleum Type) ❑lb. PREMIUM UNLEADED ❑ 3. DIESEL ❑ 6. AVIATION FUEL <br /> ❑ 2. NON-FUEL PETROLEUM ❑tc. MIDGRADE UNLEADED ❑ 4. GASOHOL ❑99. OTHER <br /> ❑ 3. CHEMICAL PRODUCT -4- CAS#(from Hazardous Materials Inventory page) <br /> COMMON ME fro azardous A�i(edals Inventory age) <br /> 4. HAZARDOUS WASTE(includes �, �b /}�'} I <br /> El 95.Used Oil) '(/V r{ll/// V � t ' <br /> 111.TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1. SINGLE WALL ❑ 3. SINGLE WALL WITH /C01 <br /> SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> EXTERIOR MEMBRANE LINER . UNKNOWN <br /> (Check one item only) ❑ 2. DOUBLE WALL ❑ q SINGLE WALL IN A VAULT <br /> OTHER <br /> TANK MATERIAL-primary lank ❑ 1 BARE STEEL ❑ 3. FIBERGLASS I PLASTIC ❑ 5. CONCRETE95. UNKNOWN <br /> (Check one dem only) ❑ 2. STAINLESS STEEL C14. STEEL CLAD W/FIBERGLASS E] 8 FRP COMPATIBLE W/100%METHANOL ❑99. OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL•secondary tank ❑ 1 BARE STEEL ❑ 3. FIBERGLASS/PLASTIC ❑ 8. FRP COMPATIBLE W/100%METHANOL5. UNKNOWN <br /> (Check one item only) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD W/FIBERGLASS [:19. FRP NON-CORRODIBLE JACKET '43i'99. OTHER <br /> REINFORCED PLASTIC(FRP) ❑10. COATED STEEL <br /> ❑ 5. CONCRETE <br /> TANK INTERIOR LININGDATE INSTALLED <br /> OR COATING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING 95. UNKNOWN433 <br /> ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING ❑ 6. UNLINED ❑99. OTHER (Forlocal use onl) <br /> (Check one item only) DATE INSTALLED <br /> OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC 95 UNKNOWN 434 <br /> PROTECTION IF APPLICABLE PROTECTION <br /> ❑ 4, IMPRESSED CURRENT ❑99. OTHER (For local use on/y) <br /> (Check one item only) ❑ 2. SACRIFICIAL AN,.ODE�`"o,r� <br /> SPILL AND OVERFILL /�Y AA,f J f�/�++�• �STALLEO TYPE(Forlocal use only) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (Check all that apply) ❑ 1 SPI/LLL CONTAINMENT ❑ 1. ALARM ❑ 3. FILL TUBE SHUT OFF VALVE <br /> ❑ 2. DROP TUBE ❑ 2. BALL FLOAT ❑ 4. EXEMPT <br /> ❑ 3. STRIKER PLATE <br /> IV. TANK LEAK DETECTION <br /> IF SINGLE WAIL TANK Check ell that s IF DOUBLE WALL TANK OR TANK WITH BLADDER Check one item only): <br /> ❑ 1, VISUAL(EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ 6. VADOSE ZONE ❑ 2. CONTINUOUS INTERSTITIAL MONITORING <br /> ❑ 3. CONTINUOUS ATG ❑ 7. GROUNDWATER ❑ 3. MANUAL MONITORING <br /> ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR) ❑ 8. TANK TESTING <br /> BIENNIAL TANK TESTING ❑99. OTHER <br /> V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YR/MOtDAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIALS <br /> gallons ❑Yes ❑No <br /> �7'4 eo <br /> 7/11 0,!9 1�553� <br /> CUPAFORM(4/99) \� � Formerly SWRCB Form 6 <br />