BILLING - Laserfiche WebLink

Home Browse Search

0 0 UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 (Two pages per tank) Page_of_ �-y' TYPE OF ACTION O=V. NEW PERMIT C34. AMENDED PERMIT ❑ 5. CHANGE OF INFORMATION ❑ 6. TEMPORARY TANK CLOSURE 430. (Checkomitemonly) ❑ 3. RENEWAL PERMIT ❑ 7. PERMANENTLY CLOSED ON SITE (Specify recon) (specify mann) 8. TANK REMOVED BUSINESS NAME(saarm FACILITY NAME or DBA- Doing Business As) 3. FACILITY ID: LOC TION WITHIN SITE (options) 4 I. TANK DESCRIPTION Y6,9515 AScaled plot plan with the location ofthe UST: system including buildings and lagdmarks.shaIbegubmitted:totbe local ,) TANK ID q az TANK MANUFACTURER 435. ... ,agenc COMPARTMENTALIZED TANK ❑Yes No 454. " ©��!(J If"Yei"complete ane Pacer each cmryannsnt DATE INS AILED 455. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS (YEAR/MO)o 437. ADDITIONAL DESCRIPTION (For loss, use only) 436 -, II. TANK 4 CONITNT TANK USE 439. PETROLEUM TYPE ❑ 1. MOTOR VEHICLE FUEL ❑ la. REGULAR UNLEADED440 ❑ 2. LEADED ❑ S. JET FUEL (Ifchecicd, mmplme Petroleum Type) [I lb. PREMIUM UNLEADED C1 3. DIESEL C1 6. AVIATION GAS ❑ 2. NON -FUEL PETROLEUM ❑ 10. MIDGRADE UNLEADED ❑ 4. GASOHOL C-3 99. OTHER: El 3. CHEMICAL PRODUCT COMMON NAME (Bom H.&.Matuiaklnvenmrypa8e) 441. CAStI(BomH.dous Matcrialsln) vcntorypage 443. ❑ 4. HAZARDOUS WASTE Onsudes used 0i0 7/ 95. UNKNOWN III. TANK CONSTRUCTION TYPE OF TANK SINGLE WALL ❑ 3. SINGLE WALL WITH EXTERIOR ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. (Check one item only) MEMBRANE LINER EI 95. UNKNOWN 2. DOUBLE WALL ❑ 4. SINGLE WAIL IN A VAULT 99. OTHER TANK MATERIAL-pdmuyssnk .BARE STEEL ❑3. FIBERGLASS /PLASTIC ❑5. CONCRETE ❑95. UNKNOWN 444. (Check one item only) 2. STAINLESS STEEL 04. STEEL CLAD W/FIBERGLASS El 8. FRP COMPATIBLE ❑99.OTHER: REINFORCED PLASTIC(FRP)W/100%METHANOL TANK MATERIAL - secondary 1. BARESTEEL 3. FIBERGLASS/PLASTIC 8. FRPCOMPTIBLEW/100%METHANOL ff95 .UNKNOWN 445. (Check one it.. oNy)_ [12. STAINLESS STEEL ❑ 4. STEEL CLAD WNIBERGLASS E]9. FRP NON-CORRODABLE JACKET ❑ 99. OTHER �(f REINFORCED PLASTIC (FRP) ❑ 10. COATED STEEL 5. CONCRETE TANK INTERIOR LINING D OR COATING ❑ RUBBUFL_1NE_D__rT3. EPDXY LINING 0 5. GLASS LINING 0 95. UNKNOWN a6. DATE INSTALLED 447, . ALKYD LINING ❑ 4. PHENOLIC LINING. -Jeb.. UNLINED ❑ 99. OTHER Check ane its. oN `�� OTHER CORROSION ❑ L M UFACTURED CATHODIC 3. FIBERGLASS REINFORCED PLASTIC ,�'B5. UNKNOWN 448. DATE INSTALLED 449. PROTECTION PI OTECTION ❑ 4. IMPRESSED CURRENT "❑ .OTHER I A Bcable 2. S ORIFICIAL ANODE SPILL AND OVERFILL (Check.,, tluta Ply) 01. SPILL YEAR INSTALLED 450.7 NTAINMENT TYPE 451. 1 OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 451. �J El2. DROP BE 01. ALARM ❑ 3. FILL TUBE SHUT OFF VALVE [12. BALL FLOAT El4. EXEMPT _ C3 3. STRIK R PLATE _ IV. TANK LEAK DETECTION (A. description of the monitoring programshall be submitted to the local agency.). IF SINGLE WALL TANK 453. IF DOUBLE WALL TANK OR TANK WITH BLADDER 454. (Check all that apply) - (Check one item only) VISUAL (EXPOSED PORTI ONLY) ❑ S. MANUAL TANK GAUGING (MTG) ❑ 1. VISUAL (SINGLE WALL IN VAULT ONLY) ❑ 2. AUTOMATIC TANK GAUGI 1IG (ATG) ❑ 6. VADOSE ZONE [12. CONTINUOUS INTERSTITIAL MONITORING ❑ 3. CONTINUOUS ATG ❑ 7. GROUNDWATER [13. MANUAL MONITORING ❑ 4. STATISTICAL INVENTORY RECONCILIATION ❑ 8. TANK TESTING (SIR) + BIENNIAL TANK TE 3TrNG 099. OTHER V TANK CLOSURE INFORMATION/PERMA NkNT CLOSURE IN PLACE ESTIMATED DATE LAST USED R/MO/DAY) 455- ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456, TANK FILLED WITHINERT TERIAL7 457. - (� c-, �Y gallon O / L ❑ Yes No UPCF hwfwrc-b (1/99) -1/4 1http://www.unidoc&org Rev. 02/16/00 9 q4