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UNIFIED PROGRAM CONSOLIDATED FORM <br /> o� <br /> UNDERGROUND STORAGE TANKS - TANK PAGE 1 TANKS 3 a��1D <br /> (two pages per lank) <br /> TYPEOF ACTION 111 NEW SITE PERMIT ❑ 4 ANEiNDFD PERMD' CHANGE OF INFORMATION_ ❑ 6 TEMPORARY SITE CLOSURE Page of <br /> fcho�kmunemmS dy) _ ❑ 7 PERMANENTLY CLOSED ON SIT); <br /> ❑ 3 RENEWAL PERMIT (Specify reason-fm loW of only) (SPoeifyrevon-[m Imua.eonly) ❑ S TANKREMOVED 430 <br /> BUSINESS NAME(Sure as FACILITY NAME or DEA-Doing InunnmAs) FACILITYID: <br /> USA GASOLINE#3756 3 <br /> LOCATION WITHIN SITE(optiorup <br /> 431 <br /> 1.TANK DESCRIPTION (A aoaled plot plan with the location of the US'r system including buildings and landmarks shall be submitted to the local agency.) <br /> 'TANK ID# 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK Yes No 434 <br /> Z STIP If"Yai",comPleb me page for each mmpamnenl. <br /> DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS +36 NUMBER OF COMPARTMENTS 1990 10000 437 <br /> ADDI'T'IONAL DESCRIPTION(Fm)mat me only) <br /> 438 <br /> U.TANK CONTENTS <br /> TANK USE 439 PETROLEUM TYPE <br /> 1. MOTOR VEHICLE FUEL ❑ la. REGULAR UNLEADED [12 LEADED [15, /liT FUEL 49 <br /> (lfor.kaN complete PeUokorn Type) Cl Ih. PREMIUMUNLEADED <br /> ❑3. DIESEL [16. AVIATION FUEL <br /> ❑_2 NON-FURL PE'IROLEUM ®Ic. MIDGRADE UNLEADED [14 GASOHOL ❑W.OTHER <br /> 03 CIIEMICALPRODUCT COMMON NAME (from Huardom Matena6 lmenb <br /> rypage) 411 CAS#(Gom Hverdous Matena6 Inventory page) 4/2 <br /> [14 HAZARDOUSWASTE <br /> 0mIodea U.¢d 0a) <br /> ❑95.UNKNOWN <br /> TIL 'TANK CONS-rRUCTION <br /> TYPE OF TANK I. SMGLE WALL 3, SINGLE WAIL WITH <br /> (Check one Am only) S. SINGLE WALL WITH INTERNAL DLADDERSYSIEM 443 <br /> EXTERIOR MEMBRANE LINER 09 UNKNOWN <br /> ®2 DOUBLE WALL ❑4 SIONLE WALL IN VAULT ❑99. OTHER <br /> TANK MATERIAL-Primary tank ®I. BARE STEEL ❑3. 1 ; !:!:GLASS/ 5. CONCRETE <br /> 95. UNKNOWN Oda <br /> (Ch«k we item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/NIBERGLASS ❑6. FRP COMPTIBLE W/100^h METHANOL <br /> ❑99.OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-semndarytmk 7. BARE STEEL 3. FIBERGLASS/PLASTIC 5. CONCRETE <br /> (check one item only) ❑2. STAINLESS STEEL 9S. UNKNOWN 445 <br /> ®4. STEEL CLAD W/h1B1 RGLASS ❑g, FRP WMI'TIBLE W/IOOco METHANOL ❑99.OTHER <br /> REINFORCED PLASTIC(FRP) ❑ 10 COATEDsiE-FL <br /> ❑S. CONCRETE <br /> "TANK IN7T:RIOA LINING 1.RUBBER LINED 3.EPDXY LINING 5.GLASS LINING 95.UNKNOWN 44o DATE INSTALLLD 447 <br /> OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING <br /> (Clecknocammly) ®6t1NLINED ❑99 OTHER <br /> (For bol use only) <br /> OTHER CORROSION ❑I MANUFACTURED CATHODIC ❑3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN 44g 448 <br /> PROTECTION IF APPLICABLE PROTECTION ❑41MPRESSFD CURRENT <br /> (Check one ima only) ❑2 SACRIFICIAL ANODE ❑99 OTHER <br /> SPILL AND OVERI%II.L YEAR INSTALLED Oso (Pmlm:Nusewdy) <br /> (Clwck on non apply) ®ISPILL CONTAINMENT 1990 <br /> TYPE(kMal uu nnlY) 451 OVERFILL PROTECTION EQUIPMENT YEAR INSTALLED 452 <br /> ®2 DROP TUBE1990 ® 1 ALARM [j3 FILL TUBE SHUT OFF VALVE. <br /> ®3 STRIKER PLATE ®2 BALL FLOAT ❑4 EXEWT' <br /> 1990 <br /> IV.TANK LEAK DETECTION(A dosc"Pam of We mordtoorg Program slWl be submitted b dw Ioc.1 agmry.) <br /> IF SINGLE WALL TANK(check.11 dol.PPly) 453 IF DOUBLE W ALL TANK OR TANK WITH BLADDF 4 <br /> 454 <br /> ❑I VISUAL(EXPOSED PORTION OHL Y) 115 MANUAL TANK GAUGING MTG (Chitem only) <br /> ( ) ❑1 I VIS (SINGLE WALL IN VAULT ONLY) <br /> ❑2 AUI'OMATIC TANK GAUGING(ATG) 116 VADOSE ZONE N 2 CONTINUOUS INTERSTITIAL MONITORING <br /> ❑3 CONTINUOUS ATG ❑7GROUNDWATER ❑3 MANUAL MONITORING <br /> ❑43 1 ATISTICAL INVENTORY RECONCILIATION ❑8 TANK TESTING <br /> (SIR) BIENNIAL TANK TESTING ❑990THER <br /> IV.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YR/MO/DAy) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINNG 41% TANK FILLED WITH INERT MATERIAL? 457 <br /> gallons ❑Yes ❑ No <br /> UPCF(1/99 revised) Formerly SWRCB Form B <br />