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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 (two pages per tank) Page-of TYPE"OF ACTION ❑I NEW SITE PERMIT ED4 AMENDED PERMIT El5 CHANGE OF INFORMATION [16 TEMPORARY SITE CLOSURE (Check one item only) ❑ 7 PERMANENTLY CLOSED ON SITE ® 3 RENEWAL PERMIT (Specify reason-for local use only) (Specify reason-for local use only) ❑ 8 TANK REMOVED 430 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) FACILITY ID: I 3 My Mini Mart LOCATION WITHIN SITE(optional) 431 Between Store and Pumps I.TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local agency.) TANK ID 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK IN Yes ❑ No 434 87 RUL#1 Preoared Modern Buildina Company If"Yci",complete one page for each compartment. DATE INSTALLED(YEARJMO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 1998 12,000 2 ADDITIONAL DESCRIPTION(For local use only) 438 II.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 410 IM 1, MOTOR VEHICLE FUEL M 1 a. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (lfmarkcdcompletcPetrolcumType) ❑ lb. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION FUEL ❑2. NON-FUEL PETROLEUM ❑ 1c. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER ❑3. CI-iEMICAL PRODUCT COMMON NAME (from Hazardous Materials Inventory page) 411 CAS#(from Hazardous Materials Inventory page.) 442 ❑4. HAZARDOUS WASTE (Includes Uscd Oil) ❑95.UNKNOWN 11:1. TANK CONSTRUCTION TYPE OF TANK 1. SINGLE WALL. U 3. SINGLE WALL WITI1 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one iters only) EXTERIOR MEMBRANE LINER ❑95. UNKNOWN i�2. DOUBLE WALL [14. SIGNLE WALL IN VAULT ❑99. OTHER TANK MATERIAL-primary tank I. BARE STEEL 3. FIBERGLASS!PLASTIC 5. CONCRETE LJ 95. UNKNOWN 444 (Check one itoni only) ❑2. STAINLESS STEEL DO 4, STEEL CLAD W/FIBERGLASS ❑8, FRP COMPTIBLE W1100✓METHANOL [:199.OTI IER REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary tank 1. BARE STEEL 3. FIBERGLASS/PLAS°CIC 5. CONCRETE ET95. UNKNOWN 445 (Check one item only) ❑2. STAINLESS STEEL N 4. STEEL CLAD WIFIBERGLASS E18, FRP COMPTIBLE W/100%METHANOL ❑99,OTHER REINFORCED PLASTIC(FRP) ❑10.COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING ❑ L RUBBER LINED ❑3.EPDXY LINING 5.GLASS LINING ❑95.UNKNOWN 446 DATE INSTALLED 447 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING ❑6 UNLINED ❑99 OTHER (Check one item only) (For local use only) OTHER CORROSION ❑l MANUFACTURED CATHODIC 0 3 FIBERGLASS REINFORCED PLASTIC ❑9f UNKNOWN 448 DATE INSTALLED 449 PROTECTION IF APPLICABLE PROTECTION ❑4IMPRESSED CURRENT ❑99 OTHER (Check one item only) ❑2 SACRIFICIAL ANODE (For local use only) SPILL AND OVERFILL YEAR INSTALLED t),Z3 450 TYPE(local use only) 451 OVERFILL PROTECTION EQUIPMENI':YL"•AR INSTALLED 452 (Check all that apply) M 1 SPILL CONTAINMENT M I ALARM ®2 DROP TUBE El FILL TUBE SHUT OFF VALVE ®2 BALL FLOAT ❑4 EXEMPT 3 STRIKER PLATE IV.TANK LEAK DETECTION(A description of the monitoringprogtam shall be submitted to the local agcncy.) IF SINGLE WALL TANK(Check all that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 El VISUAL(EXPOSED PORTION ONLY) ElMTG ( )5 MANUAL TANK GAUGING (Cheek one.item(SIonl:,1 VISUAL(SINGLE WALL IN VAULT ONLY) ❑2 AUTOMATIC TANK GAUGING(ATG) ❑6 VADOSE ZONE ❑2 CONTINUOUS INTERSTITIAL MONITORING ❑3 CONTINUOUS ATG ❑7 GROUNDWATER ❑3 MANUAL MONITORING 4 STATISTICAL INVENTORY RECONCILIATION ❑S TANK TESTING (SIR) BIENNIAL TANK TESTING ❑99 OTHER IV.TANK CLOSURE INFORMATION J PERMANENT CLOSURE IN PLACE FILLED WITH INERT MATERIAL? 457 ESTIMATED DATE LAST USED(YR/MO/DAY) 455 D QUANTiTY OF SUBSTANCE REMAINING 456 TANK gallons 1-1 Yes ESTIMATE ❑ No UPCF(12/99 revised) 10 Formerly SWRCB Form B