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D PROGRAM CONSOLIDATED FO _ TANKS UNDERGROUND STORAGE TANKS-TANK PAGE i (two pages per tank) Page dJ of TYPE OF ACTION I NEW SITE PERMIT ❑ 4 AhIENDED PERAIIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Check one item only) ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT (Specifyreason-forlocalusemAY) (Sparr$'reason-fotlocalnseonh-) [I8 TANKREMOVED 430 1 Y ID BU INESS AME(saline ACII f1 Y 4I D13A- 8,; s Aa) FACILIT 40 Gly 7 G S v 3 3 431 LOCATION WITHIN SITE(Optional) L 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# 432 TA M NUFACTURER 433 COIvIPARTNIENTALIZED TANK Yes ❑No 434 it ® 0� �, Gc1 If`Yes",complete one page for each compartment. DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONY 436 NUMBER OF COMPARTMENTS 4.3- C©3 . 438 ADDITIONAL DESCRIPTION(For local use only) H.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 01.MOTOR VEHICLE FUEL ❑In. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (If marked complete Petroleum Type) 0(lb. PREMIUM UNLEADED ❑3.DIESEL ❑6. AVIATION FUEL ❑2.NON-FUEL PETROLEUM ❑lc. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER ❑ '1`l, 3. CHEMICAL PRODUCT COMMON NAME (from Hazardous Materials Inventory page) 441 CAS#(from Hazardous Materials Inventory page) ❑4. HAZARDOUS WASTE (Includes Used Oil) ❑45.UNKNOWN HL TANK CONSTRUCTION TYPE OF TANK 1. SINGLE WALL 3. SINGLE WALL WITH 0 5, SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one item only) EXTERIOR MEMBRANE LINER 095.UNKNOWN K2. DOUBLE WALL [14. SIGNLE W ALL IN VAULT ❑99. OTHER UNKNOWN 414 TANK ALATERIALInraR'tank 1.BARES EL 3.FIBERGLASS/PLASTIC CONCRETE 5. 95. - n (Check one item only) ❑2 STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS ❑8. FRP COIAIPTIBLE W%100°e A-IETIiANOL ❑99.OTHER REINFORCED PLASTIC(FRP) TANK hLATERIAL-=ecoudarytank 1. BARE STEEL 3.FIBERGLASS/I, S. CONCRETE 95,UNKNOWN 445 (check one item only) ❑2. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS 138. FRP COMPTIBLE W/100°4 1JETHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10.COATED STEEL ❑5.CONCRETE TANK INTERIOR LINING 0 1.RUBBER LINED 3.EPDXY LINING 5.GLASS LINING 5.UNKNOWN 446 DATE INSTALLED 44' OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING ❑6 UNLINED ❑99 OTHER IFor local nse ogle) (Check oon item only) 448 DATE INSTALLED 449 OTHER CORROSION ❑1 ALANLTFA(_-nTRED CATHODIC ❑3 FIBERGLASS REINFORCED PLASTIC W95 UNKNOWN PROTECTION IF APPLICABLE PROTECTION ❑4 IMPRESSED CURRENT ❑99 OTHER (For local nse only) (Check one item only) ❑2 SACRIFICIAL ANODE SPILL AND OV SILL YEAR INSTALLED 450 TYPE(local use arty) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 45-' (Checkall"apply) 1 SPILL CONTAINMENT ❑1 ALARM ❑3 FILL TUBE SHUT OFF VALVE 2 DROP TUBE Fr2 BALL FLOAT ❑4 EXEMPT 3 STRIKER PLATE PLTANK LEAK DETECTION(A description of the monitoring lxogram shall be submitted to the local agency.) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 IF SINGLE WALL TANK(Check all that apply) (Check one item only) ❑1 VISUAL(EXPOSED PORTION ONLY) ❑5 h-LANLTAL TANK GATTGgNG(hITG) ❑1 VISUAL(SINGLE WALL IN VAULT ONLY) ❑2 AUTOMATIC TANK GAUGING(ATG) ❑6 VADOSE ZONE Pr2 CONTINUOUS INTERSTITIAL MONITORING ❑3 CONTINUOUS ATG ❑7 GROUNDWATER ❑3 MANUAL MONITORING [J 4 STATISTICAL INVENTORY RECONCILIATION ❑8 TANK TESTING (SIR) BIENNIAL TANK TESTING ❑99 OTHER W.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 4'" ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 45 gallons ❑Yes ❑ No UPCF(12/99 revised) 10 Formerly SWRCB Form B