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IFIED PROGRAM CONSOLIDATED FORW TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 1 (t-pages per tank) page-..of-. TYPE OF ACTION ❑1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Check one imn only) ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT (Specify reavm-forloc anseonly) (SPe'+fyimicam-f«local uscody) ❑ 8 TANK REMOVED 430 BUSINESS NAM (Same as FACILnYNAWw08A-Domgl As) FACILITY ID: 1 LOCATION WITHIN SITE(opioml) 431 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 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK ❑Yes f No 434 -MoglJr keryel K"Yei,cmplee one pose for each compaMkeo<. DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 It v ADDITIONAL DESCRIPTION(For bol nse ooly) 439 IL TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 ❑1. MOTOR VEHICLE FUEL ❑I& REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (ifrnorked comphee Petroletan Tom) ❑Ib. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION FUEL ❑2. NON-FUEL PETROLEUM ❑!c. MIDGRADE UNLEADED [14. GASOHOL O�99.OTHER ❑3. CHEMICAL PRODUCT COMMON NAME(from Hamdms Materials invam y page) 441 CAS#(from Harardoas Maeriaha Imrmtay page) 442 K4. HAZARDOUS WASTE (Inclu lm Used Oil) ❑95.UNKNOWN III. TANK CONSTRUCTION TYPE OF TANK El 1. SINGLE WALL 3. SINGLE WALL WITH 5, SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one faro only) EXTERIOR MEMBRANE LINER ❑95. UNKNOWN UK DOUBLE WALL ❑4. SIGNLE WALL IN VAULT ❑99. OTHER TANK MATERIAL-primmy not 0 1. BARE STEEL . FIBERGLASS/PLASTIC Ll 5. CONCRETE E3 95. UNKNOWN 444 (Check oneocan only) ❑2. STAINLESS STEEL [14, STEEL CLAD W/FIBERGLASS ❑8. FRP COMPTIBLE W/(00%METHANOL [199.OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary net D 1. BARE STEEL . FIBERGLASS/PLASTIC 0 5, CONCRETE D 95. UNKNOWN M5 (Check one dem only) ❑2. STAINLESS STEEL [:14. STEEL CLAD W/FIBERGLASS [18. FRPCOMPTBLE W/I00%MECHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) [110.COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING L RUBBER LINED 0 3.EPDXY LINING 0 5.GLASS LINING 95.UNKNOWN 446 DATE INSTALLED 447 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING (UNLINED ❑99 OTHER _ (Check onei-only) (Farloot nscouly) OTHER CORROSION ❑I MANUFACTURED CATHODIC ❑3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN 448 DATE INSTALLED 449 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 4550 TYPE(loaj 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Check aM datapply) A]SPILL CONTAINMENT tlQ` { Or4 ALARM `qj9 ❑3FILL TUBE SHUT OFF VALVE §!&DROP TUBE %V0 ❑2 BALL FLOAT ❑4 EXEMPT / 2<3 STRIKER PLATE I'J" IV.TANK LEAK DETECTION(A description of the mombrmg program shall be submitted m the loot agency) IF SINGLE WALL TANK(Check a9 that appy) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 (Check one item only) ❑1 VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MTG) ❑1 VISUAL(SINGLE WALL IN VAULT ONLY) ❑2 AUTOMATIC TANK GAUGING(ATG) ❑6 VADOSE ZONE 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(12199 revised) 10 Formerly SWRCB Form B