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01"..'(iN1F1ED PROGRAM CONSOLIDATED VkMwo Z 0b TANKS OW 2 UNDERGROUND STORAGE TANKS - TANK PAGE 1 (Two pages per tank) Page_of TYPE OF ACTION ❑ 1.NEW PERMIT ® 4.AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION ❑ &TEMPORARY TANK CLOSURE 430. (Check can item only) ❑ 3.RENEWAL PERMIT Equipment Modification ❑ 7.PERMANENTLY CLOSED ON SITE (Specify reason) (Spanify«aatn) ❑ S.TANK REMOVED BUSINESS NAMES.u FACILITY NAME or DBA-Doing Business As) 3. FACILITY ID: l „� I' Ahmed's Chevron " ' LOCATION WITHIN SITE(optional) I ^ ^ 431' <(B,IJ 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 ❑Yes ❑ No 434. Unknown If"Yes,"complete one past for each wmputment 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS 437 DATE INSTALLED - (YEAR/MO) Unknown 12,000 1 ADDITIONAL DESCRIPTION(For low on only) 433. H.TANK CONTENTS TANK USE 439, PETROLEUM TYPE 440. ® 1. MOTOR VEHICLE FUEL ® 1 a. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL prchaccktd,complete Petroleum Type) ❑Ib. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑Ic. MIDGRADE UNLEADED [14. GASOHOL ❑99.OTHER; ❑ 3. CHEMICAL PRODUCT COMMON NAME (fiom HaZmdon9 Materials inventory page) 441CAS#(from Heautioos Millions inventory page) 442_ ❑ 4. HAZARDOUS WASTE (Includes Used oil) ❑ 95.UNKNOWN III. TANK CONSTRUCTION TYPE OF TANK ❑1. SINGLE WALL [13. SINGLE WALL WITH EXTERIOR [15. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. (Check one item only) MEMBRANE LINER ❑95. UNKNOWN ®2. DOUBLE WALL ❑4. SINGLE WALL M A VAULT ❑99. OTHER TANK MATERIAL-primary tank ❑1. BARE STEEL ❑3. FIBERGLASS/PLASTIC ❑5. CONCRETE [195.UNKNOWN 444. (Check one item only) ❑2. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS ®8. FRP COMPATIBLE ❑99.OTHER: REINFORCED PLASTIC FRP W1100%METHANOL TANK MATERIAL-secondary tank ❑1. BARE STEEL ❑3. FIBERGLASS/PLASTIC ®8. FRP COMPTIBLE W/100%METHANOL 95.UNKNOWN 445. (Check one item only) ❑2. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS [19. FRP NON-CORRODABLE JACKET [199,OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING [11.RUBBER LINED ❑J.EPDXY LINING LJ 5.GLASS LINING 0 95.UNKNOWN 446, DATE INSTALLED 447. OR COATING ❑2.ALKYD LINING [14.PHENOLIC LINING ®6.UNLINED ❑99.OTHER Check one item only) OTHER CORROSION ❑I.MANUFAC I URED CATHODIC ❑3.FIBERGLASS REINFORCED PLASTIC ❑95.UNKNOWN 443. DATE INSTALLED 449. PROTECTION PROTECTION [14.IMPRESSED CURRENT [199.OTHER If A licable ❑2.SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED 450. TYPE 451, OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 452. (Check all that apply) ®1.SPILL CONTAINMENT Unknown ❑ 1.ALARM ®3.FILL TUBE SHUT OFF VALVE Unk ®2.DROP TUBE Unknown [12.BALL FLOAT ❑4.EXEMPT ®3.STRIKER PLATE Unknown IV.TANK LEAK DETECTION (A description of the monitoring program shall be submitted to the local agency.) IF SINGLE WALL TANK 453- IF DOUBLE WALL TANK OR TANK WITH BLADDER 454. (Check all that apply) (Check one item only) [11. VISUAL(EXPOSED PORTION ONLY) ❑5.MANUAL TANK GAUGING(MTG) ❑1.VISUAL(SINGLE WALL IN VAULT ONLY) ❑2. AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE ®2.CONTINUOUS INTERSTITIAL MONITORING [13. CONTINUOUS ATG [17.GROUNDWATER [13.MANUAL MONITORING [14. STATISTICAL INVENTORY RECONCILIATION [18.TANK TESTING (SIR),BIENNIAL TANK TESTING ❑99. OTHER V.TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 455' ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL, 451 gallons ❑Yes ❑ No UPCF hwfwre-b(1/99)-1/4 http://www.unidocs.org Rev.02/16/00