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s AMD PROGRAM CONSOLIDATED FO �ERGRp TANKS �JND STORAGE TANKS - TANK PAGE Z TYPE OF ACTIONI-NEW PERMIT (Two pages per tank) (Check one item only) ❑ 3.RE ❑ 4.AMENDED PERMIT Page�6( RENEWAL PERMIT ❑ 5-CHANGE OF INFORMATION ❑ 6 TEMPORARY TANK CLOSURE BUSINESS N (Specify reason) ❑ 7.PERM 430. GAME(game as FACILITY NA (SlmlfY reason) ANENTLY CLOSED ON SITE / ✓T - r IarDBA-Doing Business As) 3, FACILITY ID: ❑ 8.TANK REMOVED LOCATION WITHIN SITE(Optional) Lam , 1. I. TANK DESCRIPTION 43 t. (A scaled plot plan with the Location of the UST IPTION TANK ID�j system including buildings 433 TAMC MANI]FACTtJRER 'and landmarks shall be Submitted to the local agency.), 433. COMPARTMENTALIZED TANK ATE INSTALLED �cX✓TiC7i n !✓T a35. ('Ti. F ❑Yes No (YEAR/MO) TANK CAPACITY IN GALLONS' � A36. II"Ye>.,compltte one Pelle for each rotnPeRnsea[. 434. 2-CO5 0 NUMBER OF COMPAR ADDITIONAL DESCRIPTION(For local use only) QCa� TMENTS 437. TANK USEII.T 438. MOTOR VEHICLE FUEL a39. PETROLEUM TYPE TANK CONTENTS I. (IfcheckedcompletePeuoleumType) Ola' REGULAR UNLEADED ❑t b. PREMIU ❑2. LEADED ❑ 2. NON-FUEL PETROLEUM UNLEADED 440. ❑ 3. CHEMIC ❑ M Ic. MIDGRADE UNLEADED 3. DIESEL El 5. ]Er FUEL❑6. AVIATION GAS AL PRODUCT ❑4. GASOHOL ❑ 4. HAZARDOUS W COMMON NAME (tom H ❑9`9.OTHER: Include U WASTE axardow Matersats Invent" 44 i. { used Oil) CAS# (Gom Flazardous Materials Inventory Page) ❑ 95.UNKNOWN ) "2. TYPE OF TANK III. TANK CONS Z.TRi]CTION (Check one item only) ❑I° SINGLE WALL ❑3. SINGLE WALL WITH MEMBRANE LINER EXTERIOR ❑5. SINGLE WALL WITH INTERNAL BLADDER 5YSTISM aa3_ TANK MATERIAL- 2' DOOUBLE WALL 4. SINGLE W ❑95. UNKNOWN prtn'�Y tank 1. BARE STEEL ALL IN A VAULT (Check one item only) 3• FIBERGLASS/PLASTIC ❑99. OTHER ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑5. CONCRETE ❑8- FRP COMPATIBLE ❑95.UNKNOWN TANK MATERIAL-seconds tank REINFORCED PLASTIC FRP ' 7 ❑ L BARE STEEL 3. FIBERGLASS i PLASTIC W/100%METHANOL ❑99.OTHER: (Check one item only) ❑2- STAINLESS STEEL ❑$• FRP CO ❑4. STEEL CLAD W/FIBERGLASS MPTIBLE W/i00%METHANOL REINFORCED PLASTIC FRP ❑1 FRP NON-CORRODABLE JACKET ❑95.UNK�OWN ass. TANK INTERIOR LINING ❑5. CONCRETE ( } ❑l0. COATED STEEL ❑99.OTHER OR COATING ❑ 1.RUBBER LINED ❑3.EPDXY LINING ~ Check one item only) ❑2.ALKYD LINING ❑4.PHENOLIC LINING ❑5 GLASS LINING 5.UNKNOWN OTHER CORROSION ❑6 UM QYED ❑99.OTHER 446, DATE INSTALLED 447 --- PROTECTION ❑1 MANUFACTUREQ CATHODIC �� PROTECTION 3•FIBERGLASS REINFORCED PLASTIC 95. �- IfA licable ❑2.SACRIFICIAL ANODE ❑4.IMPRESSED CURRENT UNKNOWN 448. DATE INSTALLED 449. SPILL AND OVERFILL ❑99-OTHER (Check all that apply EAR ti'NSTALLED 450. PP ) L SPILL CONTAINMENT /b7 TYPE 451. OVERFILL PROTECTION E ?.DROP TUBE q cf L L AL UIPMENT; YEARIN a53. 3.STRIKER PLATE AA,y1 Y-iLGG't' 3.FILL TUBE SHUT OFF VALVEd]�?w �+ �2.BALL FLOAT=_1 4.EXEMPT c' •t! . "-Iva a It IV. TANK LEAK DETECTION IF SINGLE WgLL TANK (A description of the monitoring program chalk be submitted to the local agency.) (Check tapply) as3. IF DOUBLE WALL TANK OR TANK WIT[I BLADDER Asa. ❑ 1. VISUAL L(E,'s;POSED PORTION ONLY} ❑2. AUTOMATIC TANK GAUGING, ❑5.MANUAL TANK GAllGING(MIG (Check ane item only) (ATG) ) ❑ 1.V[SL'AL{SINGLE WALL IN VAULT ONLY) ❑3. CONTINUOUS ATG ❑6.VADOSE ZONE �2.CONTIIJUOUS OYTERST]TIAL MONITORING ❑4. STATISTICAL INVENTORY RECONCILIATION ❑❑S..TANGROUNDWATER TESTING, ❑3 MANUAL MONITORING (SIR)+BIENNIAL TANK TESTING ❑99. OTHER V. TANK CLOSURE INFORMATION/ PE ESTIM ATED DATE LAST USED(YR,Mo nnY) Ass. PERMANENT CLOSURE IN PLACE ESTIMATED QUANTITY OF SUBSTANCE REMAINING ase. TANK FILLED WITH INERT MATERIAL:' 453 gallons ❑Yes ❑ No PCF hwfwrc-b(1/99)-I/4 hrtp://www.ullidoCs.org Rev.022/16/00