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.nl, re pwna _PAnn r.nNCnI InATED FORM i 1711� ., ..�r TANKS UNDER ND STORAGE TANKS - 1 rVr( PAGE L(_ .,_4 _- per tank) TYPE OF ACTION ❑ 1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE ❑ 7 PERMANENTLY CLOSED ON SITE (Check one item only) ®3 RENEWAL PERMIT (Specify reason -for local use only) (Specify reason -for local use Doty) ❑ 8 TANK REMOVED 4301 BUSINESS NAME(Sameas FACILITY NAME or DOA- Doing Business As) =FACILITY 3 Beacon Station #3492 LOCATION WITHIN SITE (Optional) 631 I. TANK DESCRIPTION (A. scaled. plot. planwith the location of the UST system including buildings and landmarks shallbe. submitted to the local agency. 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK ❑Yes ®No 434 TANK ID # 3492-1 _F4 Wb I Q7 Trusco IYYes , complete one page for each compartment DATE INSTALLED (YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 12/98 14000 1 ADDITIONAL DESCRIPTION (Far local use only) 438 II. TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 ® 1. MOTOR VEHICLE FUEL ® la. REGULAR UNLEADED [12. LEADED ❑ 5. JET FUEL (If marked complete Petroleum Type) ❑ 1b. PREMIUM UNLEADED ❑ 3. DIESEL [16. AVIATION FUEL ❑ 2. NON -FUEL PETROLEUM []lc. MIDGRADE UNLEADED ❑ 4. GASOHOL ❑ 99. OTHER ❑ 3. CHEMICAL PRODUCT 441 CAS# (from Hazardous Materials Inventory page) COMMON NAME (from Hazardous Materials Inventory page) 442 [14, HAZARDOUS WASTE 8006-61-9 (includes Used Oil) [195. UNKNOWN III. TANK CONSTRUCTION TYPE OF TANK El 1. SINGLE", LL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 EXTERIOR MEMBRANE LINER El 95. UNKNOWN (Check one item only) 92. DOUBLE WALL ❑ 4. SIGNLE WALL IN VAULT [199. OTHER TANK MATERIAL-primarytank ®1. BARE STEEL ❑ 3. FIBERGLASS /PLASTIC ❑ 5. CONCRETE -195. UNKNOWN 444 (Check one Item only) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD W/FIBERGLASS ❑ 8. FRP COMPATIBLE W/ ❑ 99. OTHER REINFORCED PLASTIC (FRP) 100% METHANOL TANKMATERUT secondary tank ❑1. BARE STEEL ®3. FIBERGLASS/PLASTIC ❑5. CONCRETE ❑95. UNKNOWN 445 ❑ 2. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS ❑ 8. FRP COMPATIBLE [199. OTHER (Check one item only) REINFORCED PLASTIC (FRP) Wil 00%METHANOL ❑ 5. CONCRETE ❑ 10. COATED STEEL DATE INSTALLED 447 TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING [15. GLASS LINING ❑ 95. UNKNOWN 446 OR COATING ❑ 2 ALKYD LINING ❑ 4 PHENOLIC LINING ®6 UNLINED ❑ 99 OTHER (For local use only) (Check one item only) 446 GATE INSTALLED 449 OTHER CORROSION ❑ i MANUFACTURED CATHODIC ❑ 3 FIBERGLASS REINFORCED PLASTIC ❑ 95 UNKNOWN PROTECTION IF APPLICABLE PROTECTION ❑ 4 IMPRESSED CURRENT ❑ 99 OTHER (For local use only) (Check one item only) ❑2 SACRIFICIAL ANODE 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 SPILL AND OVERFILL YEAR INSTALLED 450 TYPE (local use only)) (Check all ® 1 SPILL CONTAINMENT 1998 ® 1 ALARM ® 3 FILL TUBE SHUT OFF VALVE that apply) 1998 ❑ 2 BALL FLOAT ❑ 4 EXEMPT ®2 DROP TUBE ® 3 STRIKER PLATE 1998 - IV. TANK LEAK DETECTION (A description of the monitoring program shall be submitted to Me local agency.) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 IF SINGLE WALL TANK (Check all that apply) (Check one item only) ❑ i 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 ❑ 3 CONTINUOUS ATG ❑ 7 GROUNDWATER ❑ 3 MANUAL MONITORING ❑ 4 STATISTICAL INVENTORY RECONCILIATION ❑ 8 TANK TESTING +(SIR) BIENNIAL TANK TESTING ❑99OTHER IV. TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE 455 ESTIMATED QUANTITY OF SUBSTANCE 456 TANK FILLED WITH INERT MATERIAL? 457 [ESTIM�ATEDDATELAST USED (YR/MO/DAY) REMAINING El Yes ❑ No gallons UPCF (1/99 revised) 0 0 Formerly SWRCB Form B