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I U� <br /> FIED PROGRAM CONSOLIDATED FO;* f+ r* r IJ/r0Y <br /> c� <br /> ' TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAG <br /> (two pages per nnk) <br /> _ <br /> TYPE OF ACTION ANEW SITE PERMIT C 4 AMENDED PERMIT C 5 CHANGE OF INFORMATION C 6 TEMPORARY SITE CLOSURE Pye_aTqj-3�6)w <br /> (c. .®aalyl O 7 PERMANENTLY CLOSED ON SITE <br /> ❑ 3 RENEWAL PERMIT (Spafy eaamo-fm bul unaonly) (Spacffy n-f.ba WY) S TANKREMOVED Am <br /> $ NA�(Samsas FACILITY NA or DBA-Doing Buemt/u) FACILPfy ID: 1 <br /> Jo .J c Cemr-1. k ' FA 5 <br /> LOCATION WITHIN SITE(O,b ) 431 <br /> 1.TANK DESCRIPTION (A scaled plot plan with the location of the UST system including builchngs and landmarks shall be submitted to the local agency.) <br /> TANK ID# 433 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK Ya No AN <br /> UN/\ Imw.aaml.a ane pw f.aeLamgarom <br /> DATE INSTALLED(YEAR/MO) 415 TANK CAPACITY IN GALLONS AM NUMBER OF COMPARTMENTS 437 <br /> iL) G SO <br /> ADDITIONAL DESCRIPTION ff.ba me aroyl 4>a <br /> R.TANK CONTENTS <br /> -;7N TUEE 419 PETROLEUM TYPE .ac <br /> 0 L MOTOR VEHICLE FUEL C la. REGULAR UNLEADED C 2. LEADED ❑5. JET FUEL <br /> Of I.n Peaol.m Ty ) C Ib. PREMIUM UNLEADED C3.DIESEL L16. AVIATION FUbl <br /> Z)2.NON-FUEL PETROLEUM C Ic. MIDGRADE UNLEADED C4. GASOHOL C)99.OTHER <br /> 03. CHEMICAL PRODUCT COMMON NAME (immHamaw Mm aM aaam YPge) 411 CAS#(fmm f nidus Mammo b u. PF) 441 <br /> Q4. HA ARDOUS WASTE <br /> fl n tbe4 DB) <br /> OWN <br /> III. TANK CONSTRUCTION <br /> TYPE OF TANK .. SINGLE WALL LI 3. SINGLE WALL WTTF: jj 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 <br /> (dckas®only) EITERIORMEMBIL NELINER 095. UNKNOWN _ <br /> C2. DOUBLE WALL ❑4. SIGNLE WALLIN VAULT C99. OTTER <br /> TANK MATERIAL Z;E= BARESTEEL L3 3. FIBERGLASS I PL.A:'.TIC Lj 5. CONCRETE 0 95. UNKNOWN 444 <br /> (oaten¢®adr) ❑2. STAINLESS STEEL 04.STEEL CLAD W/FTEZRGLASS Cl B. FRP COMPTTBLE W/100%METHANOL Cl 99.OTHER <br /> REINFORCED PLA ,71C(FRP) <br /> TATA MATERIAL_. aad.yu 1. BARESTEEL 3. FIBERGLASS I PL.STIC Ll 5. CONCRETE LJ 95. UNKNOWN 445 <br /> (0 s -.anly) C 2. STAINLESS STEEL Cl 4.STEEL CAD W/FBERGLASS 0%. FRP COMPTIBLE W/100°/.METHANOL C 99.OTHER <br /> REINFORCED PI SITC(FRP) 0 10.COATED STEEL <br /> 5. CONCRETE <br /> TANK INTERIOR LINING EILRUBBERLINED LJ 3.EPDXY LINING �:Z[S.GLASS LINING El 95.UNKNOWN <br /> e46 DATEINSTAILED 447 <br /> C <br /> OR COATING 2 ALKYD LINING []4 PHENOLIC L R41NG ,:/UNLINED cl 99 OTHER <br /> (Oeok:.®emly) (F.ha.only) <br /> OTHER CORROSION ❑1 MANUFACTURED CATHODIC ❑3 FIBERGLASS REINFORCED PLASTIC D 95 UNKNOWN 4u DATE INSTALLED 449 <br /> PROTECTION IFAPPLICABLE PROTECTION 4IMPRESSED CURRENT C 99 OTHER <br /> Torts®my) 02 SACRIFICIAL ANODE (F.ba aa:only) <br /> SPILL AND OVERFILL YEAR INSTAII ED AM TYPE(baa .iy, 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 4Q <br /> (Q�afltaaw*) ❑I SPILL CONTAINMENT []1 ALARM D 3 FILL TUBE SHUT OFF VALVE <br /> ❑2 DROP TUBE D 2 BALL FLOAT Ll 4 EXEMPT <br /> ❑3 STRIKER PLATE <br /> IV.TANK LEAK DETECTION(AJeanbom of4eemwio�vispap®n>ell eeommimanme beak asmcy.) <br /> IF SINGLE WALL TANK AM IF DOUBLE WALL TANK OR TANK WITH BLADDER AN <br /> fc . s®amy) <br /> C I VISUAL QD[POSED PORTION ONLY) C 5 MANUAL TANK GAUGING(MTG) C I VISUAL(SINGLE WALLIN VAULT ONLY) <br /> C 2 ALTRIMATICTANK GAUGING(ATG) D 6 VADOSE TONE C 2 CONTINUOUS INTERSTITIAL MONITORING <br /> C 3 CONTINUOUS ATG C 7 GROUNDWATER C 3 MANUAL MONITORING <br /> ❑4 STATISTICAL INVENTORY RECONCILIATION C8TANK TESTING <br /> (SIR) BIENNIAL TANK TESTING []99 OTHER <br /> IV.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YR/MO/DAY) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 436 TANK FILLED WITH INERT MATERIAL? 457 <br /> PROW ❑Yes C No <br /> UPCF(12/99 revised) 10 Formerly SWRCB Form B <br />