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IFIED PROGRAM CONSOLIDATED TA UNDER� OSTORAGE TANKS -TAS PAGE $ (two Pamte Page_of_ TYPE OF ACTION ❑1 NEW SITE PERM£P ❑ 4 AMENDED PERMIT 0 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Check one item only) ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWALPERMIT (Speafyrea5on-f0rI0cmIu5eonly) (SgecWYmason-forlocaluseoniy) ❑ 8 TANKREMOVED 430 13USIMSS NAME(Same as FACWY NAME 3 or DBA-Domg Bumim As) FACILITY ID: SBC#ESCLCAI l ="'` ---- LOCATION WITHIN SITE(Optional) -- - 431 L TANK DESCRIPTION (A scaled plot plan with the location ofthe UST systm including buildings and landmarks shall be submittedto the local agency.) TANK ID# 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK ❑Yes No 434 1 Modem If"Yes,cornpide one page for each compartmemt DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 2004 ))060 ADDITIONAL DESCRIPTION(For local use only) 438 II.TANK CONTENTS TANK USE 439 PETROLEUM TYPE -:::�i 1.MOTOR VEHICLE FUEL ❑1& REGULAR UNLEADED ❑2. LEADED ❑5. IRT FUEL 440 (Ifmarked complete Pdroleum Type) ❑Ib. PREMIUM UNLEADED ®3. DIESEL ❑6. AVIATION FUEL, ❑Z NON-FUEL PETROLEUM ❑1c. MIDCRtADE UNLEADED ❑4. GASOHOL ❑99.OTTIHR_ ❑3. CHEMICAL PRODUCT COMMON NAME(from Hazardous Materials lnventorypage) 441 CAS#(fiom Hazatdatts Materials lnvertmy page) 442 ❑4. HAZARDOUS WASTE (IrmhOes Used Oil) ❑95.UNKNOWN TIL TANK CONSTRUCTION TYPE OF TANK EJ 1. SINGLE WALL 0 3. SINGLE WALL U 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Chackone item ordy) EXTERIOR MEMBRANE 095. UNKNOWN ®2. DOUBLE WALL ❑4. SIGNLE WALL IN VAULT ❑99. OTTER TANKMATERIAL-prtrwytank 1.BARE STEEL 0 3. FIBERGLASS/PLASTIC 0 5. CONCRETE 13 95. UNKNOWN 444 (Check one dam only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FI ERGLASS ❑g.FRP COMPTIBLE W/100%MSTHANOL ❑99.OTI-ER REINFORCED PLASTIC(FRP) TANK MATERIAL-semnda y tank El 1.BARE STEEL E3 3. FIBERGLASS/PLASTIC El 5. CONCRETE 0 95. UNKNOWN 445 (Cherdkoneitem only) ❑2. STAINLESS STEEL ®4. STEEL.CLAD W/FTBERGL ASS ❑8. FRP COMPTIBLE W/100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10.COATED STEEL ❑5. CONCRETE TANK INTERIOR 124ING 1.RUBBER LINED 3.EPDXY LINING 5.GLASS LINING El 95.UNKNOWN 446 DATE INSTALLED 447 OR COATING ®2 ALKYD LINING ❑4 PHENOLIC LINING 06UNLINED ❑99 OTHER (Chedkoneitem only) (Far local use only) OTHER CORROSION ❑1 MANUFACTURED CATHODIC ❑3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN 44s PROTECTION IF APPLICABLE PROTECTION ❑4IMPRESSED NT' ❑99 OTHER (Cherkoneitemonly) ❑2SACRIFICIAL ANODE (Forlocaluseonly) SPILL AND OVERFILL YEAR INSTALLED 450 TYPEpoaduseonly) 451 OVERFILL PROTECIIONEQUIPMENTNEAR.INSTALLED 452 (Check all that apply) ®I SPILL CONTAINMENT 2004 ®1 ALARM 2004 El 3 FILL.TUBS SHUT OFF VALVE ®2 DROP TUBE 2004 ❑2 BALL FLOAT ❑4 FJ(EMPT 3 STRIKER PLATE 2004 IV.TANK LEAK DETECTION(Adescr4dorofthem progtamshallbesubmiuedtothe low agency.) IF SINGLE WALL TANK(Check in that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 ❑1 VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING ®UAL SINGLE WALL IN VAULT ONLY) ❑2 AUTOMATIC TANK GAUGING(ATG) ❑6 VADOSE SONE 0 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} a55 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANTO FILLED WITH INERT MATERIAL? 457 gallons ❑Yes 0 No