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UNIFIED PROGRAM CONSOLIDATED FORM b*t, 0\ UNDERGROUND STORAGE TANKS - TANK PAGE 1 3�-;,.2,\03 TANKS 3 (two Pagas per lank) TYPE OF ACTION ❑ 1 NEW SITE PERMIT ❑ 4 AMENDED PERMITx -5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Check one item only) ___ _ ❑ 7 PERMANENTLY CLOSED ON SITE El3 RENEWAL PERMIT (Specify reason-for local use only) (Specify reason-for local use only) ❑ 8 TANK REMOVED I)u 13USINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) I I FACILITY ID: USA GASOLINE#3696 1 ' IFA 3 S LOCATION WI'T'HIN SITE(optional) t31 1.TANK DESCRIPTION (A scaled plot plan with the location ofthe UST system including buildings and landmarks shall be submitted to the local agency.) "TANK ID# 432 TANK MANUFACTURER 473 COMPART'MEN'T'ALIZE'D TANK ❑Yes ® No 434 '7 (o O WENS CORNING If"Yes".complete one page for each comparuncrit. Y DATE INSTALLED(YEAR/MO) 475 TANK CAPACITY IN GALLONS 430 NUMBER OF COMPAR'T'MENTS 437 1989 10000 ADDITIONAL DESCRIPTION(Fur local use only) 3X II.TANK CONTENTS TANK USE 439 PETROLEUM TYPE ®I. MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED ❑2. LEADEDIn ❑5. JET FUEL (If marked complete Petroleum Type) ❑1 b. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION FUEL ❑2. NON-FUEL PETROLEUM ®Ic MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER ❑3. CHEMICAL PRODUCT COMMON NAME (from Hazardous Materials Inventory page) t't CAS#(from Hazardous Materials Inventory page) 142 ❑4. HAZARDOUS WASTE (Includes Used Gil) ❑95.UNKNOWN III. 'TANK(:'ONSTRUCTION TYPE OF TANK ❑I SINGLE WALL Cl 3. SINGLE WALL WITH ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one item only) EXTERIOR MEMBRANE LINER [195. 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 ilatn only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPTIBLE W/1000/0 ME'I'HANOI, ❑99.OTHER REINFORCED PLASTIC(FRY) TANK MATERIAL-secondary lank ❑1. BARE STEEL 3. FIBERGLASS/PLASTIC ❑5. CONCRETE 0 95. UNKNOWN 445 (Check one item only) ❑2. STAINLESS STEEL ®4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPTIBLE W/100%METHANOL ❑99.O'T'HER REINFORCED PLASTIC(FRP) ❑10.COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING El 1.RUBBER LINED U 3.EPDXY LINING 5.GLASS LINING U 95,UNKNOWN 446 DATE INS'T'ALLED 447 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING (Check one item only) ®61JNLINF.11 ❑99 OTHER (For local use only) OTHER CORROSION ❑ 1 MANUFACTURED CATHODIC ❑3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN 448 448 PROTECTION IF APPLICABLE PROTECTION ❑4 IMPRESSED CURRENT ❑99 OTHER (Check one item only) ❑2 SACRIFICIAL ANODE (For 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 ®2 DROP TUBE 1)g� ®3 FILL TUBE SHUT OFF VALVE ❑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.) IF SINGLE WALL"TANK(Check all that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 ❑ I VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING (Cheek one item only) (MTG) ❑1 VISUAL(SINGLE WALL IN VAULT ONLY) ❑'_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 456 TANK FILLED WITH INERT MATERIAL? 457 gallons ❑Yes ❑ No UPCF(1/99 revised) Formerly SWRCB Form B