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IED PROGRAM CONSOLIDATED FORM" O / TANKS 1 kkC O UNDERGROUND STORAGE TANKS-TANK PAGE I (Two pag fl) Lw Page_of TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 4.AMENDED PERMIT ❑ 5.CHANGE OF INFO N ❑ 6.TE CLOSURE 430. (Chale om item only) ❑ 3.RENEWAL PERMIT 7 CLOSED ON SITE (Specify reason) (specify raesm) 8.T MOVED BU=NAME(Same as FACILITY NAME or DBA-Irving ncsiams M) 3. FACILITYID: rly y"icMicS1EA\ 411, LOCATION WITHIN SITE(optional) 1 1.TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shall be-submitted tothe local agency.) TANK ID# 432. TANK-MANUFACTURER 431 COMPARTMENTALIZED TANK ®Yes No 434. ',.� N 1�1E.lOit-)liC If"Yee;'complete one page for each compartment. DATE INST LED 435_ TANK CAPACITY IN GAXLyONS -�/(; 436. NUMBER OF COMPARTMENTS 077 (YEAR/MO) o�)IO6O S\`�, kd-Id ADDITIONAL DESCRIPTpIOlN(Por lour ou onty) 418' U.TANK CONTENTS TANK USE 439. PETROLEUM TYPE ono. 'V I. MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL pfchaked.complete Petmleem Type) ®16 PREMIUM UNLEADED 03. DIESEL ❑6. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑In. MIDGRADE UNLEADED [14. GASOHOL ❑99.OTHER: ❑ 3. CHEMICAL PRODUCT COMMONNAME (from Haaawoua Muaials towatery,page) 441_ CAS#(from Hmerdons Materials lnveatmy page) 4,12. ❑ 4. HAZARDOUS WASTE (Inchrdee Deed Oil) J ❑ 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 LL ❑WA4. SINGLE WALL IN A VAULT ❑99. OTHER TANK MATERIAL-primuy tank 111. BARE STEEL ❑3. FIBERGLASS/PLASTIC [15. CONCRETE [195.UNKNOWN 4H. (Check oro item only) [12. STAINLESS STEEL [14, STEEL CLAD W/FIBERGLASS [18. FRP COMPATIBLE ❑99.OTHER: REINFORCED PLASTICW/100%METHANOL TANK MATERIAL-secondary tank 01. BARE STEEL 503. FIBERGLASS/PLASTIC C3 8. FRP COMPTIBLE W/100%METHANOL 095.UNKNOWN 445. (Check one item only) [12. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS [19. FRP NON-CORRODABLE JACKET [199.OTHER REINFORCED PLASTIC(FRP) [110. COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING 1.RUBBER LINED ❑3.EPDXY LINING [15.GLASS LINING [195.UNKNOWN 446. DATE INSTALLED 447, OR COATING ❑2.ALKYD LINING ❑4.PHENOLIC LINING IA 6.UNLINED [199.OTHER Check one item only) OTHER CORROSION ❑1.MANUFACTURED CATHODIC [13.FIBERGLASS REINFORCED PLASTIC [195.UNKNOWN 448. DATE INSTALLED N9, PROTECTION PROTECTION [14.IMPRESSED CURRENT [199.OTHER IfApplicable) ❑2.SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED 450, TYPE 451. OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 452. (Check all that apply) t4 1.SPILL CONTAINMENT 0 9KA--vk{e 111.ALARM Q 3.FILL TUBE SHUT OFF VALVE CLIC 2.DROP TUBE Q� CiPVl $1 2.BALL FLOAT /1S ❑4.EXEMPT 3.STRIKER PLATE W.TANK LEAK DETECTION (A description of the monitoring program shall be submitted to the localagency.) 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) ❑5.MANUAL TANK GAUGING(MTG) ❑1.VISUAL(SINGLE WALL IN VAULT ONLY) ❑2.AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE [12.CONTINUOUS INTERSTITIAL MONITORING ❑3.CONTINUOUS ATG ❑7.GROUNDWATER [13.MANUAL MONITORING ❑4. STATISTICAL INVENTORY RECONCILIATION ❑8.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.unidocs.org Rev.02/16/00