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Ur�MED PROGRAM CONSOLIDATED'V61IN TANKS 2 UNDERGROUND STORAGE TANKS - TANK PAGE 1 �� g,�p (Tw pages lt"itt c) Page_of TYPE OF ACTION ❑ 1.NEW PERMIT ® 4.AMENDED PERMIT ❑ S.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430 (Check one imm only) ❑ 3.RENEWAL PERMIT Equipment Modification ❑ 7.PERMANENTLY CLOSED ON SITE (Specify rasion) (Specify won) ❑ 8.TANK REMOVED BUSINESS NAME(Same u FACILITY NAME or DBA-Doing Business As) 3, 1 FACILITY ID: 7 1 Ahmed's Chevron LOCATION WITHIN SITE(optiona0 431_ 1.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 p 432. TANK MANUFACTURER 433. COMPARTMENTALIZED TANK ❑Yes ❑ No 434. Unknown If"Yes,"complete one page for each compartment DATE INSTALLED 435, TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS 431. (YEAR/MO) Unknown 12,000 1 ADDITIONAL DESCRIPTION(For local me only) 439. II.TANK CONTENTS TANK USE 439, PETROLEUM TYPE 440. ® 1. MOTOR VEHICLE FUEL ❑2. LEADED ❑5. JET FUEL (Ifchecked,complete Petroleum Type) ®Ib. PREMIUM UNLEADED '� 03. DIESEL 06. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑le. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME (from Hazardous Materials Inventory page) 441CASH(Item Hazardous Materials Inventory page) 442. ❑ 4. HAZARDOUS WASTE (Includes Used Oil) ❑ 95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK ❑ I. SINGLE WALL ❑3. SINGLE WALL WITH EXTERIOR ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. (Check one item only) MEMBRANE LINER ❑95. UNKNOWN ®2. DOUBLE WALL [14. SINGLE WALL M A VAULT ❑99. OTHER TANK MATERIAL-primary tank ❑1. BARE STEEL ❑3. FIBERGLASS/PLASTIC ❑5. CONCRETE ❑95.UNKNOWN 4" (Check one item only) ❑2. STAINLESS STEEL [14, STEEL CLAD W/FIBERGLASS ®8. FRP COMPATIBLE ❑99.OTHER: REINFORCED PLASTIC FRP W/100%METHANOL TANK MATERIAL-secondary tank [31. BARE STEEL ❑3. FIBERGLASS/PLASTIC 8. FRP COMPTBSLE W/100%METHANOL ❑95.UNKNOWN 445. (Check one item only) ❑2. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS ❑9. FRP NON-CORRODABLE JACKET ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING 1.RUBBER LINED ❑3.EPDXY LINING El5.GLASS LINING 95.UNKNOWN 446. DATE INSTALLED 447. OR COATING ❑2.ALKYD LINING ❑4.PHENOLIC LINING ®6.UNLINED ❑99.OTHER Check one item onlyh OTHER CORROSION I.MANUFACTURED CATHODIC ❑3.FIBERGLASS REINFORCED PLASTIC 95.UNKNOWN 449. DATE INSTALLED 449. PROTECTION PROTECTION ❑4.IMPRESSED CURRENT ❑99.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 [11.ALARM ®3.FILL TUBE SHUT OFF VALVE Unk ®2.DROP TUBE Unknown ❑2.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) ❑ 1. VISUAL(EXPOSED PORTION ONLY) [15.MANUAL TANK GAUGING(MTG) ❑1.VISUAL(SINGLE WALL IN VAULT ONLY) ❑2.AUTOMATIC TANK GAUGING(ATG) [:16.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 099. 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? 457 gallons ❑Yes ❑ No UPCF hwfwrc-b(1/99)-1/4 http://www.unidoc&org Rev.02/16/00