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AL AL ED PROGRAM CONSOLIDATED Fif TANKS UNDERTTOUND STORAGE TANKS - TANK PAGE 1 (two pages per tank) Page_of_ TYPE OF ACTION ❑I NEW SITE PERMIT 'a 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Click om item only) ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWALPERMIT (Specifymnwn-forloeWu4 oNy) (Specify�um-forbcalureonly) ❑ 8 TANKREMOVED 430 BUSINESS NAME(Smm.a FACILITY NAMEorDSA-Duing Business As) FACILITY IDI ,t I 3 ' -f- e- u oN LOCATION WITHIN SITE(opiba4 431 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# (( a32 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK Yes ❑ No 434 V k I( -Now (V UW f< N O w N H"Yee,wrnpkte one page mr ee hwn4 emmut. DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 4M NUMBER OF COMPARTMENTS 437 L) NI4. UbW W ADDITIONAL DESCRIPTION 438 IL TANK CONTENTS TANK USE 439 PETROLEUM TYPE �o MI. MOTOR VEHICLE FUEL M la. REGULAR UNLEADED [12. LEADED ❑5. JET FUEL (n marked mn lae Pewleumlype) ®Ib. PREMIUM UNLEADED ®3. DIESEL ❑6. AVIATION FUEL ❑2. NON-FURL PETROLEUM M Ic. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER ❑3. CHEMICAL PRODUCT COMMON NAME (6om Hae. w MLLeris hrremmy Page) 441 CAS#(6.m Haamdous Mm.dls inventory peg.) 442 E14. HAZARDOUS WASTE (w:bda used Oil) ❑95.UNKNOWN III. TANK CONSTRUCTION TYPEOFTANK 01. SINGLE WALL ❑3. SINGLE WALL WITH 05. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Chckomimmonly) EXTERIOR MEMBRANE LINER ❑95. UNKNOWN 2. DOUBLE WALL ❑4. SIGNLE W ALL IN VAULT ❑99. OTHER TANK MATERIAL-pli tank 0 1. BAESTEEL 0 3. FIBERGLASS/PLASTIC ❑5. CONCRETE 095. UNKNOWN 444 (Click om item oNy) ❑2. STAINLESS STEEL 04. STEEL CLAD W/FIBERGLASS 08. FRP COMPTIBLE W1100%METHANOL 099.OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-woudmy mnlc ❑1. BARE STEEL 3. FIBERGLASS/PLASTIC S. CONCRETE 95. UNKNOWN 445 (Chckoro hemonly7 02. STAINLESS STEEL e4. STEEL CLAD W/FIBERGLASS 0. FRP COMPTIBLE W/100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10.COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING ❑1.RUBBER LINED ❑3.EPDXY LINING [15.GLASS LINING ❑95.UNKNOWN DATE INSTALLED 447 OR COATING ❑2 ALKYD LINING 1-14 PHENOLIC LINING 0 6 UNLINED ❑99 OTHER (Check one itemonly) (Por 10"]use ody) qqg 446 OTHER CORROSION ❑1 MANUFACTURED CATHODIC M 3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN PROTECTION IF APPLICABLE PROTECTION ❑4IMPRESSED CURRENT ❑99 OTHER (Check.rc!.mo.ly) ❑2 SACRIFICIAL ANODE (kt bcd use only) SPILL AND OVERFILL YEAR INSTALLED 2.00+450 TYPE(bmlux only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Ch.kdl tont apPly) I SPILL CONTAINMENT El ALARM M 3 FILL TUBE SHUT OFF VALVE ®2 DROP TUBE ❑2 BALL FLOAT ❑4 EXEMPT ®3 STRIKER PLATE O O 41- IV.TANK LEAK DETECTION(A desmiplion of the monitoring Iwgmm sh.11b wd ted.the beat W..cy.) IF SINGLE WALL TANK(c k an thm apply) 453 IF DOUBLE WALL TANK OR TANK W 1TF7 BLADDER 454 (check.ve item Daly) ❑1 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 ❑99 OTHER IV.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK PHI FD W ATH RTME4 57 gallons [I IN ❑ IIPCF(1/99 revised) 173 Formerly SWRCB Form B