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EDP ROGRAM CONSOLIDATED FO TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 1 (two pages per lank) Page _ of TYPE OF ACTION 111.NEW SITE PERMIT ❑ 4. AMENDED PERMIT ❑ 5. CHANGE OF INFORMATION) ❑ 8. TEMPORARY SITE CLOSURE (Check one item only) ❑ ?, PERMANENTLY CLOSED ON SITE 0 RENEWAL PERMIT SpxM maaan-bro alv aoM) (Spacly charge-mrbnl use only) ❑ B. TANK REMOVED 409 BUSINESS NAME(Sams se FACILITY NAME or DBA-Doing Business As) FACILITY IO R t LOCATION WITHIN SITE(Op8ena9 431 g 9 o M•zra� �� Y a I.TANK DESCRIPTION TANK 10a TANK MANUFACTURER COMPARTMENTALIZED TANK ❑ Yea ❑ No M04UyL W r�\ a If Hee',mmplale one page for eacM1 compartment DATE INSTALLED(YEARAMO) TANK CAPACITY IN GALLONNUMBER OF COMPARTMENTS 19`87 �2� ADDITIONAL DESCRIPTION(Forlocal use only) II.TANK CONTENTS TANK USE 432 PETROLEUM TYPE 1 MOTOR VEHICLE FUEL ❑1a. REGULAR UNLEADED F4GAS D ❑ 5. JET FUEL (1/man:ed,compels Pollpleum Type) ❑tD. PREMIUM UNLEADED L ❑ 8. AVIATION FUEL ❑ 2. NON-FUEL PETROLEUM 1<. MIDGRAOE UNLEADED HOL ❑99. OTHER ❑ 3. CHEMICAL PRODUCT COMMON NAME(ham Harallous Malemis lmm anbrypage) CAS N(ImHasanfous Materials Inrenlory page) 13 4 HAZARDOUS WASTE(IMudaa Usad 0' 0 Its UNKNOWN 111.TANK CONSTRUCTION TYPE OF TANK ccc�❑y111....1 SINGLE WALL ❑ 3. SINGLE WALL WITH 115. SINGLE WALL WITH INTERNAL BLAODER SYSTEM (CMck am dem any) 12112. DOUBLE WALL EXTERIOR MEMBRANE LINER ❑95. UNKNOWN !e�_ ❑ 4. SINGLE WALL IN A VAULT ❑99 OTHER TANK MATERIAL.pnmary tank ❑ 1 BARE STEEL ��a❑ 3, FIBERGLASS I PLASTIC ❑ 5. CONCRETE ❑95. UNKNOWN (Cmc4 ons item aMy) ❑ 2. STAINLESS STEEL Ly 4. STEEL CLAD WIFIBERGLASS ❑ 8. FRP COMPATIBLE Wl 10%METHANOL 099. OTHER I REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary lank ❑ 1 BARE STEEL ...�.....❑��AAApee 3. FIBERGLASS I PLASTIC ❑ 8. FRP COMPATIBLE WlIW%METHANOL 11 S& UNKNOWN (Check am item omy) ❑ 2. STAINLESS STEEL 'Tf,34. STEEL CUD WIFIBERGLASS ❑ 9. FRP NON-CORRODIBLE JACKET 099. OTHER / REINFORCED PLASTIC(FRP) ❑10 COATED STEEL ❑ 5. CONCRETE TANK INTERIOR LINING ❑ 1RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING ❑95. UNKNOM433 DATE INSTALLED OR COATING . - ❑ 2.ALKYD LINING ❑ 4. PHENOLIC LINING ❑ 8. UNLINED ❑99. OTHER (Check me item o (Farlocal use onW OTHER CORROSION ❑ t. MANUFACTURED GTHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN 434 GATE INSTALLED PROTECTION IF APPLICABLE PROTECTION ❑ 4. IMPRESSED CURRENT 099. OTHER (Check one item Dory) ❑ 2. SACRIFICIAL ANODE (Forbcal use only) SPILL AND OVERFILL (Anj�vLdW L� YEARINSTALLED TYPE(For war we only) OVERFILL PROTECTION EQUIPMENT YEAR INSTALLED i (Check as that pply) 1❑•11, SPILL CONTAINMENT ❑ 1. ALARM ❑ 3. FILL TUBE SHUT OFF VALVE ❑ 2. DROP TUBE ❑ 2. SALL FLOAT ❑ 4. EXEMPT ❑ 3. STRIKER PLATE N. TANKLEAKDETECTION IF SINGLE WALL TANK Creak all that a J IIF DOUBLE WALL TANK OR TANK WITH BLADDERCMck am item only: ❑ 1. VISUAL("POSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALLIN VAULT ONLY) ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ 8. VADOSE ZONE ❑ 2. CONTINUOUS IMERSTITIAL MONITORING ❑ 3. CONTINUOUSATG ❑ ?. GROUNDWATER ❑ 3. MANUALMONITORING ❑ 4. STATISTICALINVENTORY RECONCILIATION(SIR)- ❑ S. TANKTESTING BIENNIAL TANK TESTING 0. OTHER V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YRO.ICOAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL? gallena ❑Yes ❑No CUPAFORM(4199) • • Formerly SWRCB Form B