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a yr ' UNIFIED PROGRAM CONSOLIDATED FORM p\ UNDERGROUND STORAGE TANKS - TANK P GE i TANKS 1 1:1 (two pages per tank) TYPE OF ACTION ❑ 1 NEW SITE PERMIT- ❑ 4 AMENDED PERMIT �Q 5 CHANGE OF INFORMATION Page of (Check one itnn only) "'///��` ❑ G TEMPORARY SITE CLOSURE 7 PERMANENTLY CLOSED ON SITE C1 3 RENEWAL,PERMIT (Specify reason-for local use ordy) (Specify reason-for local use only) ❑ 8 TANK REMOVED 430 BUSINESS NAME(Satre as FACILITY NAME or DBA-Doing Business As) FACILITY ID: i USA GASOLINE#3696 3 LOCATION WITHIN SITE(optional) 431 1.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 tl 432 TANK MANUFACTURER 433 COMPARTMENTALIZEDTANK ❑Yes ® No 434 &I OWENS CORNING If"Yes",com complete p page for each comparbneu. DATE INSTALLED(YEAR/MO) 435 TANK CAPACI'T'Y IN GALLONS 436 NUMBER OF COMPARTMENTS 1989 437 10000 ADDITIONAL DESCRIPTION(For local use only) 438 II.TANK CONTENTS TANK USE 439 PETROLEUM TYPE ® I. MOTOR VEHICLE FUEL ®la REGULAR UNLEADED ❑2. LEADEDt to ❑5. JET FUEL (If marked complete Petroleum Type) ❑I b. PREMIUM UNLEADED ❑3. DIESEL ❑G. AVIATION FUEL, ❑2. NON-FUEL PETROLEUM ❑Ic. MIDGRADE UNLEADED [14. GASOHOL ❑99.OTHER ❑3 CHEMICAL PRODUCT COMMON NAME (from iha.docs Materials Inventory page) MI CAS/E(from Hazardous Materials Inventory page) -142 ❑4. HAZARDOUS WASTE (Includes Used Oil) ❑95.UNKNOWN III. TANK CONSTRUCTION TYPE OF TANK ❑I. SINGLE WALL ❑3. SINGLE WALL WI"1'H ❑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 1199. OTHER TANK MATERIAL-primary tank W 1. BARE STEEL ❑3. FIBERGLASS/PLASTIC ❑5 CONCRETE ❑95 UNKNOWN 444 (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑8. FRI COMPTIBLE W/100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary tank ❑I. BARE STEEL 0 3. F'IBE'RGLASS/PLASTIC 5. CONCRETE 95. UNKNOWN t4s (Check one item only) ❑2. STAINLESS STEEL ®4. STEEL CLAD W/FIBERGLASSo ❑8. FRY COMPTIBLE W/IUO%METHANOL, 1199-OTHER REINFORCED PLASTIC(FRP) ❑10.COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING 111.RUBBER LINED 0 3.EPDXY LINING 5.GLASS LINING 95.UNKNOWN 446 DATE INSTALL-ED 447 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING 06 UNLINED one item only) ® UNLINED ❑99 OTHER (For local use only) OTHER CORROSION ❑ 1 MANUFACTURED CATHODIC ❑3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN 44g 448 PRO'T'ECTION IF APPLICABLE. PROTECTION ❑4 IMPRESSED CURRENT (Check one item only) ❑2 SACRIFICIAL ANODE ❑99 OTHER SPILL AND OVERFILL (For local use only) YEAR INSTALLED 450 TYPE(local use roily) 451 OVERFILL,PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Check all that apply) ®)SPILL CONTAINMENT 1989 ®2 DROP TUBE [II ALARM ®3 FILL TUBE SHIFT OFF VALVE 1989 ❑2 BALL FLOAT ❑4 EXEMPT ®3 STRIKER PLATE 1989 IV.TANK LEAK DETECTION(A description of the monitoring program shall be submitted to the local agency.) IP SINGLE WALL TANK(cheek au that apply) :G) TIF DOUBLE WALL TANK OR TANK WITH BLADDER454 ❑I VISUAL(EXPOSEDPORTION ONLY) ❑5 MANUAL TANK GAUGINGheck one item only)1VSUAL(SINGLE WALL IN VAULT ONLY) ❑2 AUTOMATIC TANK GAUGING(ATG) ❑6 VADOSE ZONE 2 CONTINUOUS INIRRSTITLAL 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/4O/DAY) 415 ES1'IMA'rrtD QUANTITY OF SIJBS7'ANCE REMAINING 456 "TANK FILLED WI'rl-i INERT MATERIAL? 457 gallons ❑Yes ❑ No UPCF(1/99 revised) Formerly SWRCB Form B