Laserfiche WebLink
` v UNIFIED PROGRAM CONSOLIDATED FORM O' <br /> TANKS <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 1 (Two pages per tank) <br /> Page_of_ <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 4.AMENDED PERMIT 5.CHANGE OF INFORMATION 6.TEMPORARY <br /> TANK L ONSITE 430 <br /> (Check one item only) ❑ 3.RENEWAL PERMIT 7.❑ 8.TANK REMOVED <br /> (Specify season) (Specify reason) <br /> I. <br /> BUSINESS NAM E(SameazFACN.rIY NAME m DBA-Doing Business As) 3, FACILITY 1q: <br /> K3zA c� ^�ti per`(' 431. <br /> LOCATFI N W T ITE(optional) <br /> �A V I q S . H I.TANK DESCRIPTION <br /> (A scaled plot plan with.the location of the UST system Including buildings and landmarks shall be submitted to the local agency.) <br /> TANK ID# 432. TANK MANUFACTURER 433. COMPARTMENTALIZED TANK ❑Yes No 434. <br /> D�1� v �-=f7 � If"Y<s;' -1W0 om page for rachw�anment. <br /> DATE INSTALLED <br /> 43s. TA/\NKGCF_APACITY IN GALLONS 436, NUMBER OF COMPARTMENTS 437. <br /> ADDITIONAL DESCRIPTION(For lows use only) <br /> 8/V�0-3 438. <br /> II.TANK CONTENTS' <br /> 440. <br /> TANK USE 439 PETROLEUM TYPE <br /> ❑ 1. MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL <br /> (Ifchccked.compine PCuolet-TyPe) ❑lb. PREMIUM UNLEADED 03. DIESEL ❑6. AVIATION GAS <br /> ❑ 2. NON-FUEL PETROLEUM ❑lc. MIDGRADE UNLEADED [14. GASOHOL ❑99.OTHER: <br /> ❑ 3. CHEMICAL PRODUCT COMMON NAME (from Hazardous materials Inventory page) <br /> 441. CAS#(from Haza dom Mmcrials Inventory page) 442. <br /> [14. HAZARDOUS WASTE <br /> (Includes Used Oil) <br /> ❑ 95.UNKNOWN <br /> IIL TANK CONSTRUCTION <br /> TYPE Of TANK ❑L SINGLE WALL ❑3. SINGLE WALL WITH EXTERIOR [3;. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443_ <br /> TYPEoneitemonly) MEMBRANE LINER ❑95. UNKNOWN <br /> ❑2. DOUBLE WALL ❑4. SINGLE WALL IN A VAULT ❑99. OTHER 444 <br /> TANK MATERIAL-prin'-+rY taNs ❑1. BARE STEEL ❑3. FBERGLASS/PLASTIC ❑5. CONCRETE ❑95.UNKNOWN <br /> (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS [18. FRP COMPATIBLE [199.OTHER: <br /> REINFORCED PLASTIC FRP W/100%METHANOL <br /> TANK MATE secondary tank ❑l. BARE STEEL 03. FBERGLASS/PLASTIC ❑8. FRP COMPTIBLE W/I00%METHANGL ❑95.UNKNOWN aa5. <br /> (Check one item only) ❑2. STAINLESS STEEL❑4. STEELCLAD REINFORCED PLASBERGLASS 9. PIP,TIC C(FRP) ❑Il). COATEDORRODABLE JACKET ❑99.OTHER <br /> TEEL <br /> ❑5. CONCRETE <br /> TANK INTERIOR LINING ❑ L RUBBER LINED ❑3.EPDXY LINING ❑5.GLASS LINING ❑95.UNKNOWN 446. DATE INSTALLED 44y. <br /> OR COATING [12.ALKYD LINING ❑4.PHENOLIC LINING ❑6.UNLINED ❑99.OTHER <br /> Check one item only) _ <br /> OTHER CORROSION ❑1' PROTECTIOTN ED CATHODIC O 4.tMPaES ED CURRENT 99. <br /> PLASTIC O 99.OTHER WY a4s' DATEINSTALLED 449, <br /> PROTECTION <br /> IfA licable <br /> [12.SACRIFICIAL ANODE <br /> SPILL AND OVERFILL 52, <br /> YEAR INSTALLED a5o. TYPE 451. 0'.AL OTECTION>❑Q.FILL TUBE SHUTOFFVALVE a <br /> (Check all that apply) O 2.DROP CONTAINMENT <br /> ❑2.BALL FLOAT_ ❑4.EXEMPT <br /> TUBE <br /> ❑3.STRIKER PLATE <br /> IV.TANK LEAK DETECTION <br /> (A description of the monitoring program shall be d to the local agency.) <br /> 053, I DOUBLE WALL TANK OR TANK WITH BLADDER 454, <br /> IF SINGLE W ALL TANK (Check one item only) <br /> (Check all that apply) <br /> ❑1.VISUAL(EXPOSED PORTION ONLY) ❑S.MANUAL TANK GAUGING(MTG) ❑1.VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑2.AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE ❑2.CONTINUOUS INTERSTITIAL MONITORING <br /> ❑3. CONTINUOUS ATG ❑7.GROUNDWATER ❑3.MANUAL MONITORING <br /> ❑4. STATISTICAL INVENTORY RECONCILIATION 08.TANK TESTING <br /> (SIR)+BIENNIAL TANK TESTING ❑99. OTHER <br /> V.TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YRIMO/DAY) 45r. <br /> 41' ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456. TANK FILLED WITH INERT MATERIAL?gallons ❑Yes [3No <br /> Rev.02/16/00 <br /> UPCF hwfwrc-b(1/99)-11 h"p!//www.unidocs.org <br />