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IFIED PROGRAM CONSOLIDATED FC <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 <br /> (ftq pages per tank) <br /> Page _ of <br /> TYPE OF ACTION 1 NEW SITE PERMIT ❑ 4. AMENDED PERMIT ❑ 5. CHANGE OF INFORMATION) ❑ 0. TEMPORARY SITE CLOSURE <br /> (Check oM item only) <br /> ❑ C1].RENEWAL PERMIT 7 PERMANENTLY CLOSED ON SITE <br /> (Speafy mason-for local use only) (Specsy change-for local use only) <br /> ❑ B TANK REMOVED 430 <br /> BUSINESS NAME(Same as FACILITY NAME or OBA-Owg Business As) FACILITY 100 <br /> 1 <br /> TTNTTP.T) nA_-, Ej I I I F <br /> LOCATION WITHIN SITE(OpuoQw) 471 <br /> 1.TANK DESCRIPTION <br /> TANK ID a TANK MANUFACTURER COMPARTMENTALIZED TANK ❑ Yes JD No <br /> TR U S C 0 If'Yes compwte one page nor each compartment. <br /> DATE INSTALLED(YEAR/MO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> 10-99 10, 000 <br /> ADDITIONAL DESCRIPTION(For local use only) ( 1 <br /> 0 �l� <br /> 11.TANK CONTENTS <br /> TANK USE 472 PETROLEUM TYPE <br /> ® 1. MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED -0'TrEnme- ❑ 5. JET FUEL <br /> (if marked.compete Petroleum Type) U 1C. PREMIUM UNLEADED ❑ 3. DIESEL ❑ 6.AVIATION FUEL <br /> ❑ 2. NON-FUEL PETROLEUM ❑tc MIDGRAOE UNLEADED ❑ 4. GASOHOL ❑99. OTHER <br /> ❑ ]. CHEMICAL PRODUCT <br /> ❑ 4. HAZARDOUS WASTE(Irxsuoes COMMON NAME(hwn Hazardous Matenals Inventory page) CAS a(hom Hazahsous Matena/s In-wory page) i <br /> Used Od) <br /> 95 11,11NOWN <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK L❑ 1. SINGLE WALL C13. SINGLE WALLWITH C15. SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> (Chock one dyy <br /> em only) 2. DOUBLE WALL EXTERIOR MEMBRANE LINER <br /> ❑95. UNKNOWN <br /> ❑ 4. SINGLE WALL IN A VAULT ❑99 OTHER <br /> TANK MATERIAL-pnmary tank `❑ t BARE STEEL ❑ 3 FIBERGLASS!PLASTIC ❑ 5 CONCRETE ❑95 UNKNOWN <br /> (Check-sem only) ❑ 2. STAINLESS STEEL 4. STEEL CLAD W/FIBERGLASS ❑ & FRP COMPATIBLE W/1W%METHANOL ❑99 OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-secondary tank ❑ 1 BARE STEEL ❑ 3. FIBERGLASS/PLASTIC ❑ S. FRP COMPATIBLE W/700%METHANOL ❑95. UNKNOWN <br /> (Chock one dem only) ❑ 2. STAINLESS STEEL 4. STEEL CLAD W/FIBERGLASS ❑ 9. FRP NON-CORRODIBLE JACKET ❑99. OTHER <br /> REINFORCED PLASTIC(FRP) ❑10. COATED STEEL <br /> ❑ 5. CONCRETE <br /> TANK INTERIOR LINING C11. RUBBER LINED ❑ 3. EPDXY LINING C15. GLASS LINING C395. UNKNOWN437 DATE INSTALLED <br /> OR COATING <br /> (Choc*one.tem o ) ❑ 2. ALKYD LINING C14. PHENOLIC LINING C16. UNLINED 1:199. OTHER <br /> (Far tical use ) <br /> OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC C 3. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN 474 GATE INSTALLED <br /> PROTECTION IF APPLICABLE <br /> PROTECTION ❑ 4. IMPRESSED CURRENT ❑99. OTHER <br /> (Choc*one dem only) ❑ 2. SACRIFICIAL ANODE I T (Flo local use only) <br /> SPILL AND OVERFILL YEAR INSTALLED TYPE(Flo local use only) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (Check all that apply) 1� <br /> � <br /> 1. SPILL CONTAINMENT 1. ALARM ,tail. FILL TUBE SHUT OFF VALVE <br /> 2. DROP TUBE <br /> 2. BALL FLOAT ❑ 4. EXEMPT <br /> 3. STRIKER PLATE <br /> IV. TANK LEAK DETECTION <br /> IF SINGLE WALL TANK Check ax that apply): IF DOUBLE WALL TANK OR TANK WITH BLA DOER(Check one dent only): <br /> ❑ 1. VISUAL(EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GANGING(MTG) ❑ 1. VISUAL(SINGLE WALLIN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ S. VADOSE ZONE M2. CONTINUOUS INTERSTITIAL MONITORING <br /> ❑ 3. CONTINUOUS ATG ❑ 7. GROUNDWATER ❑ ]. MANUAL MONITORING <br /> ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR)- ❑ B. TANK TESTING <br /> BIENNIAL TANK TESTING ❑99. OTHER <br /> V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PUCE <br /> ESTIMATED DATE LAST USED(YR/MO/OAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL? <br /> gakons <br /> ❑Yrs ❑No <br /> TA-o X15 �f sv <br /> L �a��a> <br /> :UPAFORM(4/99) <br /> Formerly SWRCB Form 13 <br />