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Adik NIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 1 (two pages per tank) ��,,,,,, // Page _ of TYPE OF ACTION ❑1.NEWSITE PERMIT ❑ 4.AMENDED PERMIT V2 CHANGE OF INFORMATION) ❑ 6. TEMPORARY SITE CLOSURE (Checkonattemanlylli+ �i ^1 11 7. PERMANENTLY CLOSED ON SITE ❑3.RENEWAL PERMIT (Spsdry reaaan-Idrknal uae orYy) (Specpy clMrpa-brlacel uae only) ❑ B. TANK REMOVED 430 1 nt BUSINESS NAME(Same as FACILITY NAME or DBP-Going Busimms As) FACILITY IDM 1 �a (I Y-( mgb LOCATION WITHIN SITE(0phonal) 1 3212 Pd . A-g-Ag2c I.TANK DESCRIPTION TANK ID#_3 I �0/ II� II TANK MANUFACTURER '(J^ COMPARTMENTALIZED TANK �Yac ❑ No IYVes',wmplela one papa br each wmparlment. DATE INSTALLED(YPARAIO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS ADDITIONAL DESCRIPTION(For local uae omW 11.TANK CONTENTS TANK USE 432 PETROLEUM TYPE ❑ 1. MOTOR VEHICLE FUEL 111a. REGULAR UNLEADED LEADED ❑ 5.JET FUEL (p marital,wmplets Panne.Type) 11 lb. PREMIUM UNLEADED ❑ 3. DIESEL ❑ e.AVIATION FUEL ❑ 2. NOWFUEL PETROLEUM ❑1c MIDGRADE UNLEADED ❑ 4. GASOHOL 1199. OTHER ❑ 3.CHEMICAL PRODUCT ❑ 4. HAZARDOUS WASTE(Includes, COMMON NAME(Imm Hazmdpua Materials InYantorypage) CAS B Pmm Hazardous Materials In.f rypaga) Used 0" 95 UNKNOWN IS.TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM (Cheek orm item only) ❑ 2. DOUBLE WALL EXTERIOR MEMBRANE LINER 1195. UNKNOWN ❑ 4. SINGLE WALL IN A VAULT 1199. OTHER TANK MATERIAL-primary tank El 1. BARE STEEL ❑ 3. FIBERGLASS/PLASTIC ❑ 5. CONCRETE El 95. UNKNOWN (Check om Bem a*) ❑ 2. STAINLESS STEEL ❑4. STEEL CUD W/FIBERGLASS ❑ e. FRP COMPATIBLE WM00%METHANOL ❑W. OTHER REINFORCED PLASTIC(FRPI TANK MATERIAL-noordary lank 11 1 BARE STEEL ❑ 3. FIBERGLASS I PUSTIC ❑ e. FRP COMPATIBLE W/100%METHANOL 1195. UNKNOWN (Checkoraitemonly) ❑ 2. STAINLESS STEEL ❑ 4. STEELCLAQW(FIBERGLASS ❑ 9. FRP NON-CORRODIBLE JACKET El N. OTHER REINFORCED PLASTIC(FRPI ❑10. COATED STEEL ❑ 5. CONCRETE TANK INTERIOR LINING 13 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING ❑95. UNKNOM433 DATE INSTALLED OR COATING ❑ 2. ALKYD LINING ❑ C PHENOLIC LINING ❑ 9. UNLINED ❑99. OTHER Check one item on (Forlocal use om OTHER PROTECTION IF ON ❑ 1. MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PUSTIC ❑95. UNKNOWN 434 DATE INSTALLED PROTECTION IF APPLICABLE PROTECTION ❑ 4. IMPRESSED CURRENT IJ 99, OTHER (ChecN Dna item Dory) ❑ 2.SACRIFICIAL ANODE (Forlowl use only) SPILL AND OVERFILL YEAR INSTALLED TYPE(Fwldcel uae only) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED (Check all that apply) 0 1 SPILLCONTAINMENT ❑ 1. ALARM ❑ 3. FILL TUBE SHUT OFF VALVE ❑ 2. DROPTUBE ❑ 2. BALL FLOAT ❑ 4. EXEMPT ❑ 3. STRIKER PLATE W. TANK,LEAK DETECTION. IF SINGLE WALL TANK Check all theta IF DOUBLE WALL TANK OR TANK WITH BLADDER(Chack one item only): ❑ 1, VISUAL(EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING INTO) ❑ 1. VISUAL(SINGLE WALLIN VAULT ONLY) ❑ 2. AUTOMATIC TANK GAUGING(AM) ❑ e. VADOSE ZONE ❑ 2. CONTINUOUS INTERSTITIAL MONITORING ❑ 3. CONTINUOUS ATG ❑ 7. GROUNDWATER ❑ 3. MANUAL MONITORING ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR)+ ❑ B. TANKTESTING BIENNIAL TANK TESTING L1 99. OTHER V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MOMAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL? peilonn ❑Yes ❑No ��n ' Arvf V I:* CUPAFORM(4/99) • ' Formerly SWRCB Form B