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—_- ,_.,...,,erg"Uje�1„ay (7'j� <br /> tsn Site# Address t L A c "� ;'; PY <br /> `''y <br /> Date Contractor name/Tech name t/Z'0T-" <br /> ru - JAN 3 1 2017 <br /> Petroleum Storage Tanks <br /> Tank# Product Capacity UST orAST AST Impact Barrier Spllt A,`/ <br /> nk I AgKfl� !!I t, <br /> R=Regular Unloaded Nominal Gallons What type of impact barrier is TaStriker Plate no LTH <br /> Order M=Mid Grade Nearest 000 UST=Underground present?(leave blank fm USTs) TSF- <br /> per lank P=Premium ( ) Tank -Tank Striker Plate <br /> 8=Bollards F=Fencing Split Tank <br /> monitor D=Diesel (nearest..th for AST Aboveground g DSP=DropTube Striker Plate Auxilary Tank Mani(aldetl/Siphoned Tank <br /> 9 I=Inside Service Ba s <br /> W=Waste Oil ra°ka bill Nan Tank L=Located awe from traffic Yes or No N=None <br /> H=Heating Oil Soo sa°°"s) y <br /> N AST present,no barrier <br /> LINK=Unknown Yes or No (if so,to what other tank) <br /> = <br /> YES. NO <br /> z <br /> YES. NO <br /> 3 s. 1 YES NO^ <br /> 4 <br /> YES NO <br /> 5 <br /> YES NO <br /> 6 <br /> YES NO <br /> Petroleum Storage Tanks <br /> Tank# Material of Construction Corrosion Lined Tank Interstitial OR/WA/CA Vent Caps <br /> Protection S ace Remote Fill Manufacturer Model# <br /> DWF=Doublewall Fiberglass Internally Lined On( <br /> SWF=Singlewall Fiberglass Tank Does the <br /> DWS=Doublewall Steel IC=Impressed Current 8=Brine remote fill Does the UST Frl <br /> SWS=Singlewall Steel SAC=Sac Anode t•tarar•r.rr tank. 0=Dry Remote Fill have a spill Riser have a OPW <br /> DWSP=Doublewart STT �h.F°ip°"1°' VC=Vacuum bucket? tethered Write Model Number <br /> NM=Nan-metaltic ,,,,,�v net grounding cables H=Husky <br /> SWSP=Singlewall STIP UNK=Unknown N=None Yes or No M=Morrison Bros in space Provided <br /> CLD=Steel Clad w/Fiberglass UNK=Unknown YES or NO <br /> UNK=Unknown Yes or No Yes or No <br /> LINK Unknown or NA <br /> 4 <br /> 5 <br /> 6 <br /> Product Piping Vapor Recovery System <br /> Tank# Material of Siphon Bar? Carrolton Stage II <br /> Constructlon Protection Stage 1 Type (nozzle Pressure Mgm!System EVR System <br /> type <br /> DWF=OW Fberglass Does this tank dispense thry <br /> SWF=SW Fiberglass the use of a Siphon Bar 8 <br /> Order SINS=SW Steel are the connections to each IC=impressed Current BL=Balance CAS=Healy Clean Air <br /> SAC=Sac Anode 2PT=Two Point VA=Vacuum Assist per tank WRP=Wrapped tank visible? dcASeparator PT=PHIL TRE <br /> monitor NM=Non-metallic CP=Coaxial Poppeted VST=Vapor Systems Tech VR=VR Carbon Canister OPW=OPW VR <br /> Steel SV=Siphon,Co.,of visa CN=Coaxial Non-Po ted <br /> FlJ(=Flexible 5NV=Siphon,con.not visible UNK=Unknown Ppe HEVR=Healy w/EVR VST=VST Vapor Processor NA=No EVR <br /> UNK=Unknown NA=No Siphon NA=No Stage II NA=Outside of California <br /> 1s <br /> 2 Vapor Pot Does the site have a vapor pot(drop out tank)?Yes or No <br /> 3s��r E rte! y.b �` UST Monitoring System <br /> Printer Manufacturer Model Number Software Ver. <br /> 4 Does Monitor <br /> have a Printer VR=Veeder Root Write Software Version <br /> NA=None Write Model Number in space provided <br /> Yes or No in space provided <br /> 5 _ <br /> - r <br /> 6 <br /> BswtlOt/19!2016 Page 1 of 4 <br />