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,ED PROGRAM CONSOLIDATED FOS Ory TANKS UNDERGROUND STORAGE TANKS - TANK -P A o (Two pages pe•tank) Page_of_ TYPE OF ACTION �L NFV PERMIT F-1 s•AMENDED PERMIT D 5.CHANGE OF I:,TFORMATION ED 6.TEMPORARY TANK CLOSURE 430. ❑ 7.PERMANENTLY CLOSED ON SITE (Cheek 01C;tem„dy) ❑ 3.RENEWAL PERMIT ❑ 8.TANK REMOVED (Sp-ify-ft) (Spccify reason) I. BUSINESS NAME(same as FACILITY NAME or DR`A--DD1ng a""°a"�) 3 I FACILITY ID: /1 4 Cil• off- �C �i ✓'/� lB� 431. LOCATION W IN SITE(Opoo°al) L TANK DESCRIPTION rrA (A scaled plot plan with the location of the UST system including buildings and landrmnics shall be submitted to the local agency.) 1111" 1+3= TANK,VIArN)UFACTURER 433. CO �ARTMENTALIZED TANK Yes No 434. TANK IDR p /r If-ye s:wrWI to one page for each co*Var r=L -7,2 O of \ s36. NZtffiER OF COMPARTMENTS 437. DATE INSTALLED s3s. TANK CAPACrM5' N�GALLONS (YEAR/MO) rl ni,' fr 438. ADDITIONAL DESCRiPT10N(For local use only) II.TANK CONTENTS mo. TANK USE 439. PETROLEUM TYPE ED 1. MOTOR VEHU ICLE"FEL ❑la REGULAR UNLEADED ❑'_ LEADED ❑5. LET FUEL-- (if LEL(If checked corMlete Pe=io=Type) ❑ lb. PREMIUM UNLE-ADED ❑3. DIESEL ❑ 6. AyZATTON GAS ❑ 2. NON-FUEL UM PETROLE ❑Ic. MIDGRADE UNLEADED. 1714. GASOHOL ❑99.OTHER: 442. 441. CAS* (from Hazardous Materials Inventory page) ❑ 3. CHEMICAL PRODUCT COMMON NAME (from yazardous Materials Inventory Page) ❑ 4. HAZARDOL:S WASTE (Includes Used oil) 495.U`'KVOW'N III.TANK CONSTRUCTION 443. PANK"AA NK SINGLE WALL 3. SINGLE WALL WITH EXTERIOR ❑- SLGLE WALL WITH INTERNAL BLADDER SYSTEM MEMBRANE LINER ❑95. L1'KvOWN em only) a, SINGLE W ALL IN A VAULT ❑99. OTHER 4". ❑? pp(JBLE WALL ❑ 95.UNKNOWN ERIAL.-pr°rntY rmk BARE STEEL ❑3. FIBERGLASS/PLASTIC ❑5. FR?CRETE 4. STEEL CLAD W/FIBERGLASS ❑S. F2i P COMPATIBLE ❑94.OTHER: only) ❑'_. 5TAINLESSSTEEL ❑ %-!lo0'/_METHANOLREINFORCED PLASTIC4a5. ERIAL-secodary tank I. BARE STEEL 3. FIBERGLASS/PLASTIC S. FRP CO.�'CIDLE W/100%METHANOL ❑95.(JNIGNOWN ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIDERGLASS ❑9. FRP\ON-CORRODABLE JACKET ❑44.OTHER tem only) REINFORCED PLASTIC(FRP) ❑ lo. COATED STEEL ❑5. CONCRETE 4a6. DATE INSTALLED s47 TANK INTRIOR LLN�Z`G 1.RUBBER LINED 3.EPDXY LINING 5.GLASS LLNIL`G ❑99.OTHER UNKNOWN OR COATLNG ❑2.ALKYD LINING ❑s.PHENOLIC LINING W-P.UNL24ED Check one item only) S.UNKNOWN sa8. DATE INSTALLED 'ss9• OTHER CORROSION 1.MANUFACTURED CATHODIC 3.FIBERGLASS REINFORCED PLASTIC ❑99 OTHER PROTECTION ❑4.IMPRESSED CURRENT PROTECTION452 - SPILL ANODE ED 4So TYPE If Avolitabld ❑- YEAR LV ST 451. Oti'E.ztFII-L PROTECTION EQUIPMENT: YEAR INSi AlALLE SPILL AND OVERFILL +!� ❑ 1.ALARM _ ❑3.FILL TUBE SHUT OFF VALVE (Check all that apply) Q 1.SPILL 2.DROP CONTAINMENT C ❑2.BALL FLOAT__ ❑4. MPT TUBE ❑3.STRIKER PLATE IV.TANK LEAK DETECTION (A description of the monitoring program shall be subtrlitted to the local agency.) asa. asi. DOUBLE WALL TANK OR TANK WITH BLADDER IF SINGLE WALL TA.NiK (Check one iters only) (Check all that apply) 5.MANUAL TANK GAUGING(MTG) ❑ 1.VISUAL SINGLE WALL IN VAULT ONLY) ❑ 1. VISUAL(1,� SED PORTION ONLY) ❑6 VADOSE ZONE ❑Z CONTINUOUS INTERSTITIAL MOtUORING ❑2. AUTOMATIC TANK GAUGING(ATG) ❑ ❑3.CONTINUOUS ATG ❑7.GROUNDWATER ❑3.tiiANUAL MONITORING ❑4.STATISTICAL p'VE;`-TORY RECONCILIATION ❑8.TANK TESTING (SIR)-SIENNLAl TANK TESTING ❑99. OTHER CLOSURE IN PLACE V.TANK CLOSURE INFORMATION/ PERAlNINT Masi. ass. ass. TANK FILLED WITH INERT MATERIAL? ESTIMATED DATE L USED(YR/MO/DAY) ESTIMATED QUANTITY OF SUBSTANCE REV(.AINL`G ❑Yes D No gallons Rev.02/1/ 11Pf'F hwfwre-b(1/99)-114 hftp://www-unidocs.org