Laserfiche WebLink
UNIFIED PROGRAM CONSOLIDATED FORM (�/9 a3 TANK: <br />PRN: <br />UNDERGROUND STORAGE TANKS - TANK PAGE 1(EAC N' <br />`l 7 (two agespertank) <br />Page 2 of 3 <br />TYPE OF ACTION ❑ INEW SITE PERMIT ❑ 4AMENDEDPERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE <br />.. <br />(Chck only itcn, only) E]] ERMANENTLY CLOSED ON SITE <br />tip l sv «i«mry) w pmsan t taal �c udyl <br />ANKREMOVED 430 <br />El ;RENEWAL. PERMIT wl,e <br />BUSINESSNAME(Smeas FACE.rrYNAMEmoeA-Do6ig Buamus Asl <br />3 <br />FACILITY ID: <br />M <br />PRN: <br />l <br />LOCATION WITHIN Sllh(opdwW) 431 <br />PHONE <br />I. TANK DESCR PTION (A scaled plot plan wi the location of the UST system including buildings and landmarks shall be sub3lutted to the local agency.) <br />TANK IDN 432 <br />T KMANUFACTURER 433 <br />COMPARTMENTALIZED TANK E] Yes 0 N 434 <br />TA WOW <br />R-rm .wmlueoMp.ge for «n4o��pern,e,t. <br />DATE INSTALLED (YEAE/MO) 435 <br />TANK CAPACITY IN GALLONS 436 <br />NUMBER OF COMPARTMENTS 437 <br />D I NALDESCRIPTION(Fmlodueandy) 438 <br />II. TANK CONTENTS <br />TANKUSE 439 <br />PETROLEUM TYPE <br />µo <br />❑ I. MOTOR VEHICLE FUEL <br />❑ la. REGULAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL <br />(Ifoeekaeoe,neo Pen9lann Type) <br />❑ Its. PREMIUM UNLEADED ❑ 3. DIESEL ❑ 6. AVIATION FUEL <br />❑ 2.NON-FUEL PETROLEUM <br />❑ Ic.MIDGRADEUNLEADED ❑ 4. GASOHOL ❑ 99. OTHER <br />❑ 3. CHEMICAL PRODUCT <br />COMMON NAME (fian Hamdwu Mat slsl onmpeac)17= <br />µ2 <br />❑ 4. HAZARDOUS WASTE <br />oodade,usedoi0 <br />❑ 95. UNKNOWN <br />III. TANK CONSTRUCTION <br />TYPE OF TANK ❑ I. SINGLE WALL ❑ 3. SINGLE WALL W ITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTE <br />443 <br />(Cherkmei.oely) EXTERIOR MEMBRANE LINER ❑ 95. UNKNOWN <br />❑ 2. DOUBLE WALL ❑ 4. SINGLE WALL IN VAULT ❑ 99. OTHER <br />TANKMATERML-primarylank ❑ I. BARE STEEL ❑ FIBERGLASS/PLASTIC ❑ 5.CONCRETE ❑ 95.UNKNOWN <br />4µ <br />(Clirkau imnmdy) ❑ 2. STAINLESS STEEL ❑ STEEL CLAD W/FIBERGLASS ❑ S. FRP COMPTIBLE W/ IWA METHANOL <br />REINFORCED PLASTIC (FRP) ❑ 99. OTHER <br />TANK MATERIAL - secondary tank ❑ 1. BARE STEEL ❑ 3. FIBERGLASS / PLASTIC ❑ 5. CONCRETE ❑ 95. UNKNOWN <br />445 <br />(Ci xaeeitmtmly) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD W/FIBERGLASS ❑ 8. FRP COMPTIBLE W/100%METHANOL <br />REINFORCED PLASTIC (FRP) ❑ 10. COATED STEEL ❑ 99. OTHER <br />❑ 5. CONCRETE <br />µ7 <br />TANK INTERIOR LINING r-11. RUBBER LINED ❑ 3. EPDXY LINING E]5. GLASS LINING ❑ 95. UNKNOWN 446 DATE STALLED <br />ORCOATING ❑".OTHER <br />(C osei..Iy) F12ALKYD LINING ❑ 4PHENOLIC LINING E]6UNLINED (ForbdmcaNy) <br />OTHER CORROSION ❑ I MANUFACTURING CATHODIC ❑ 3 FIBERGLASS REINFORCED PLASTIC ❑ 95 UNKNOWN 44a DATE INSTALLED 449 <br />PROTECTION IF APPLICABLE PROTECTION ❑ 99 OTHER 41MPRESSED CURRENT El <br />(Caxkooe inanaNy) ❑ 2 SACRIFICIAL ANODE (Far Ivacady) <br />SPILL AND OVERFILL YEAR WSTALLE450 TYPE (lad use only) 451 <br />OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED <br />452 <br />(C6 gldunepply)❑ I SPILL CONTAINMENT <br />❑IALARM ❑ 3 FILL TUBE SHUT OFF <br />VAL` <br />❑ 2DROPTUBE <br />❑ 2BALL ❑ 4EXEMPT <br />❑ 3STRIKER PLATE <br />FLOAT <br />IV. TANK LEAK DETECTION (A devipdm of@e mmdmrmgoraBtinsM1dl <br />be Salo "d 10 Ne local agency.) <br />IF SINGLE WALL TANK (C all dun apply) 453 <br />IF DOUBLE WALL TANK OR TANK WITH BLADDER <br />454 <br />E] 1 VISUAL (EXPOSED PORTION ONLY) ❑ S MANUAL TANK GAUGING(MTG) <br />(Oh` onsi nmly) <br />E] I VISUAL (SINGLE WALL IN VAULT ONLY) <br />❑ 2 AUTOMATIC TANK GAUGING (ATG) ❑ 6 NODOSE ZONE <br />❑ 3 CONTINUOUS ATG ❑ 7 GROUNDWATER <br />❑ 2 CONTINUOUS INTERSTITIAL MONITORING <br />❑ 4 STATISTICAL INVENTORY RECONCILIATION ❑ 8 TANK TESTING <br />❑ 3 MANUAL MONITORING <br />(SIR) BIENNIAL TANK TESTING ❑ 99 OTHER <br />V. TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE <br />ESTIMATED DAT LAUSED (YR/MO/DAV) 455 <br />ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 <br />TANK FILLED W ITH INERT MA <br />ERW.7 451 <br />/q IT <br />0S <br />❑ Yes <br />No <br />UPCF (12/99 revised) 40 <br />