Laserfiche WebLink
A (©[p ?,V_ 5PLa <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TAAM <br /> UNDERGROUND STORAGE TANKS -TANK PAGE <br /> (tw gas per tank) <br /> ][ Page of <br /> TYPE OF ACTION C{,I NEW SITE PERMIT ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE <br /> (Check one item only) ( ❑ 7 PERMANENTLY CLOSED ON SITE <br /> ❑ 3 RENEWAL PERMIT (Specifyreason-forlocaluseonly) (Specifyrcason-forlocelusculy) ❑ 8 TANK REMOVED 430 <br /> BUSINESS (somata FACT YNAMe or Dep-Doing eusineu FACILITY ID: I <br /> LOCATION WITHIN SITE(optmtmq 431 <br /> 1.TANK DE CRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submi d e local agency.) <br /> TANK g4g{6,:�1Q DHof ��y/_�432 TA MANUFACTURER 433 COMPARTMENTALIZED TA Yes ❑ No 434 <br /> �pC // ! l! •5• IP'Yei',wmplete one page fm euch compttmrnt. <br /> DATE INSTILLED EA O) 435 TANK CAPACITY IN GALLO S 436 NUMBER OF COMPARTMENTS 437 <br /> ADDITIONAL DE CRIPTION(For local use only) 438 <br /> 11.TANK CONTENTS <br /> f TANK USE 439 PETROLEUM TYPE 440 <br /> ®1. MOTOR VEHICLE FUEL 11]a. REGULAR UNLEADED LEADED <br /> f mmked complete Petroleum Type) ❑5. VFUEL <br /> MfL PREMIUM UNLEADED DIESEL El 6. AVIATION FUEL <br /> [12. NON-FUEL PETROLEUM ❑to. MIDGRADE UNLEADED 4. GASOHOL ❑99.OTHER <br /> 03. CHEMICAL PRODUCT COMMON NAME (from Hunches Materials Invemory,pagc) 441 CAS//(from Heated ous Materuls Immotry page) 442 <br /> [14. HAZARDOUS WASTE <br /> (Includes Used Oil) <br /> ❑95.UNKNOWN <br /> IB. TANK CONSTRUCTION <br /> TYPE OF TANK I. SINGLE WALL LJ 3. SINGLE WALL WITH Lj 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 <br /> (Check one item only) EXTERIOR MEMBRANE LINER ❑95. UNKNOWN <br /> X2. DOUBLE WALL ❑4. SIGNLE WALL IN VAULT ❑99. OTHER <br /> TANK MATEKIAL-pdmary tank U 1. BARE STEEL 3. FIBERGLASS/PLASTIC Lj 5. CONCRETE U 95. UNKNOWN 444 <br /> (Check one item only) ❑2. STAB4I,ESB STEEL 4. STEEL CLAD W/FIBERGLASS [18. FRP COMPTIBLE W1100%METHANOL [199.OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-secondary tank Lj 1. BARE STEELFIBERGLASS/PLASTIC U 5. CONCRETE U 95. UNKNOWN 445 <br /> (Check one iam only) ❑2. STAINLESS STEEL 4. STEEL CLAD W/FBERGLASS ❑8. FRP COMPTBLE W/100%METHANOL ❑99.OTHER <br /> REINFORCED PLASTIC(FRP) ❑10.COATED STEEL <br /> ❑5. CONCRETE <br /> TANK INTERIOR LINING 0 I.RUBBER LINED 0 3.EPDXY LINING D 5.GLASS LINING LJ 95.UNKNOWN 446 DATE INS AAlLLEDD /447 <br /> OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING ❑6 UNLINED ❑99 OTHER <br /> (Check one item only) <br /> (For Intel use only) <br /> OTHER CORROSION ❑1 MANUFACTURED CATHODIC ❑3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN "' DATE INSTALLED 449 <br /> PROTECTION IF APPLICABLE PROTECTION ❑4IMPRESSED CURRENT ❑99 OTHER <br /> (Check one imm only) ❑2 SACRIFICIAL.ANODE (For local use only) <br /> SPILL AND OVERFILL YEAR INSTALLED4�s/ 450 TYPE(local use only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED � 452 <br /> (Check all that apply) &SPILL CONTAINMENT Wf 1 ALARM U�, !d'3 FILL TUBE SHUT OFF VALVE <br /> 2 DROP TUBE 96, �2 BALL FLOAT ❑4 EXEMPT <br /> 3 STRIKER PLATE Re 4 <br /> IV.TANK LEAK DETECTION(A description of the monitoring program shall be submitted to the local agency) <br /> IFSINGLE WALL TANK(auk all that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 <br /> ❑ 1 VISUAL(EXPOSED PORTION ONLY) ElMTG 5 MANUAL TANK GAUGING (Check one nem only) <br /> ( ) ❑11 VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑2 AUTOMATIC TANK GAUGING(ATG) ❑6 VADOSE ZONE1dZ CONTINUOUS INTERSTITIAL MONITORING <br /> El3 CONTINUOUS ATG ❑7 GROUNDWATER 3 MANUAL MONITORING <br /> ❑4 STATISTICAL INVENTORY RECONCILIATION ❑8 TANK TESTING <br /> (SIR) BIENNIAL TANK TESTING ❑99 OTHER <br /> IV.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YR/MO/DAY) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 <br /> gallons ❑Yes ❑ No <br /> UPCF(12/99 revised) 10 Formerly SWRCB Form B <br />