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l UNIFIED PROGRAM CONSOLIDATED FORM o 0\ �� TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 3�� (two pages per tank) �,( Pagc of TYPE OF AC'T'ION ❑ I NEW SITE PERMIT ❑ 4 AMENDED PrRM1T' Q(J 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Check one item only) "\ ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT (Specify reason-for local use only) (Specify reason-for local use only) ❑ 8 TANK REMOVED 430 BUSINESS NAME(sanne as FACILITY NAMG or DBA-Doing Business As) FACILITY ID: [___TTI USA GASOLINE#3696 LOCATION WITI(IN SITE(Optional) Ltl 1.TANK DENC'RIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local agency.) TANK II)to 432 TANK MANUFACTURER 433 COMPAR'1'MEN'I'AL.IL,ED"TANK ❑Yes ® No 434 YZEA 61q496)qO WENS CORNING If"Yes",complete one page for each compartment. DA'Z'E INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 4-� NUMBER OF COMPARTMENTS 437 1989 10000 ADDITIONAL.DESCRIPTION(For local use only) 4.3s II.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 1,10 ®1. MOTOR VEHICLE FUEL ❑)a. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (If utarked complete Petroleum 7`ype) ® 1 b. PREMIUM UNLEADED ❑3. DIIsSEI. ❑6. AVIATION FUEL ❑2. NON-FUEL PETROLEUM ❑ Ic. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER ❑3. CHEMICAL PRODUCT COMMON NAME (from Hazardous Materials Inventory page) 441 CAS#(from Hazardous Materials Inventory page) 142 ❑4. HAZARDOUS WASTE. (Includes Used Oil) ❑95.UNKNOWN III. TANK CONSTRUCTION TYPE OF TANK ❑1. SINGLE WALL ❑3. SINGLE WALL WITH ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one item only) EXTERIOR MEMBRANE LINER ❑95. UNKNOWN ®2. DOUBLE WALL ❑4. SIGNLE WALL IN VAULT ❑99. OTHER TANK MATERIAL-primary tank ® 1. BARE STEEL ❑3. FIBERGLASS/PLASTIC ❑5. CONCRETE ❑95. UNKNOWN 444 (Check one ilei only) ❑2. STAINLESS STEEL. ❑4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPTIBLE W/100%METHANOL ❑99.0711 H3R REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary tank ❑L BARE STEEL ❑3. FIBERGLASS/PLASTIC ❑5. CONCRETE ❑95. UNKNOWN 445 (Check one item only) ❑2. STAINLESS STEEL ®4. STEEL CLAD W/FIBERGLASS [:18. FRP COMPTIBLE W/100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10.COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING 0 L RUBBER LINED 0 3.EPDXY LINING 5.GLASS LINING U 95.UNKNOWN 446 DATE INSTALLED 447 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING ®6 UNLINED ❑99 OTHER (Check one item only) (For local use only) OTHER CORROSION ❑1 MANUFACTURED CATHODIC ❑3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN 448 448 PROTECTION IF APPLICABLI PROTECTION ❑4 IMPRESSED CURRENT ❑99 OTHER (Check one item only) ❑2 SACRIFICIAL ANODE (Por local use only) SPILL.AND OVERFILL YEAR INSTALLED 450 TYPE(local use only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Check all that apply) ® 1 SPILL CONTAINMENT 1989 ❑ 1 ALARM ®3 FILL TUBE SHUT OFF VALVE ®2 DROP TUBE 1989 ❑2 BALL FLOAT ❑4 EXEMPT ®3 STRIKER PLATE 1989 IV.TANK LEAK DETEUrION(A description ofthe monitoring program shall be submitted to the local agency.) IF SINGLE WALL TANK(Check all that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER t51 (Check one item only) ❑1 VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MT'G) ❑I 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 45 TANK FILLED WITH INERT MATERIAL? 457 gallons [--]Yes ❑ No UPCF(1/99 revised) Formerly SWRCB Form B