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OIFIED PROGRAM CONSOLIDATED AIM DI �1403 � TANKS yp UNDERGROUND STORAGE TANKS-TANK PAGE 1 (Two pages per lank) Page I of_2_ TYPEOF ACTION ❑ 1.NEW PERMIT ❑ 4.AMENDED PERMIT ® 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 130 (Checicone item only) ❑ 3.RENEWAL PERMIT _updated info_request ❑ 7.PERMANENTLY CLOSED ON SITE (Specify reason) (Specify reason) ❑ 8.TANK REMOVED BUS NESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3. 1 FACILITY ID: - Ame Facility No. 00595 LOCATION WITHIN SITE(optional) 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# TX 3 00/ 432. TANK MANUFACTURER 433. COMPARTMENTALIZED TANK ❑Yes ® No 434 1-LTNL-R Owens Comm If"Yes,"complete one page for each compartment. DATE INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS 437 (YEAR/MO) 12/84 12,000 1 ADDITIONAL DESCRIPTION(For local use only) 439. U.TANK CONTENTS TANK USE 439. PETROLEUM TYPE .too ® 1. MOTOR VEHICLE FUEL ®la. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (If checked,complete Petroleum Type) ❑lb. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION GAS ❑ 2.NON-FUEL PETROLEUM ❑1 c. MIDGRADE UNLEADED [14. GASOHOL ❑99.OTHER: ❑ 3.CHEMICAL PRODUCT COMMON NAME (from Hazardous Materials Inventory page) 441. CAS#(from Hazardous Materials Inventory page) 442, ❑ 4. HAZARDOUS WASTE GASOLINE (Includes Used Oil) ❑ 95.UNKNOWN M.TANK CONSTRUCTION TYPE OF TANK [11. 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 WALL [14. SINGLE WALL IN A VAULT ❑99. OTHER TANK MATERIAL-primary tank ❑1. BARE STEEL [13. FIBERGLASS/PLASTIC ❑5. CONCRETE [195.UNKNOWN 444. (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE ❑99.OTHER: REINFORCED PLASTIC W/100%METHANOL TANK MATERIAL-secondary tank ❑1. BARE STEEL ®3. FIBERGLASS/PLASTIC ❑8. FRP COMPTIBLE W/100%METHANOL ❑95.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 [11.RUBBER LINED ❑3.EPDXY LIMING ❑5.GLASS LAZING ❑95.UNKNOWN 446. DATE INSTALLED 447. OR COATING [12.ALKYD LINING ❑4.PHENOLIC LINING ®6.UNLINED ❑99.OTHER Check one item only) OTHER CORROSION [11.MANUFACTURED CATHODIC ®3.FIBERGLASS REINFORCED PLASTIC ❑95.UNKNOWN 448. DATE INSTALLED 449. PROTECTION PROTECTION ❑4.IMPRESSED CURRENT ❑99.OTHER Applicable) ❑2.SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED 450. TYPE 451. 1 OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 452. (Check all that apply) ®1.SPILL CONTAINMENT _1999_ ❑1.ALARM [13.FILL TUBE SHUT OFF VALVE ❑2.DROP TUBE ®2.BALL FLOAT 299 _ ❑4.EXEMPT ❑3.STRIKER PLATE IV.TANK LEAK DETECTION (A description of the monitoring program shall be submitted to the local agency.) IF SINGLE WALL TANK 453. IF DOUBLE WALL TANK OR TANK WITH BLADDER „4 (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) [12. AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE ®2.CONTINUOUS INTERSTITIAL MONITORING ❑3. CONTINUOUS ATG ❑7.GROUNDWATER [13.MANUAL MONITORING ❑4. STATISTICAL INVENTORY RECONCILIATION ❑8.TANK TESTING (SIR)+BIENNIAL TANK TESTING ❑99. 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 0 Yes 0 No