COMPLIANCE INFO_2001-2005 - Laserfiche WebLink

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MW IFIED PROGRAM CONSOLIDATED FORNI aft I o TANK: PR #: UNDERGROUND STORAGE TANKS - TANK PA 1 FAC #: (two pages per tank) TYPE OF ACTION Page 2 of 3 E]I NEW SITE PERMIT ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION PO AR ITE CLOSURE (Check only item only) 7 PER LY CON SITE ❑ 3 RENEWAL PERMIT t ty° > ❑ 8 TANK REMOVED 1 rtr 430 �; v. '„.�- BUSINESS NAME (Same as FACILITY NAME or DBA -Doing Business As) FACILITY ID: PR #: 3 LOCATION WITHIN SITE (Optional) I TPN ®1 1 11 9 � ((f�� PHONE 431 I. TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local agency.) TANK ID# 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK E]Yes E]No 434 bO If "Yes", complete one page for each compartment. DATE INSTALLED (YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 137 ADDITIONAL DESCRIPTION (For local use only) 438 II. TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 ❑ 1. MOTOR VEHICLE FUEL ❑ I a. REGULAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL (If marked complete Petroleum Type) ❑ Ib. PREMIUM UNLEADED ❑ 3. DIESEL ❑ 6. AVIATION FUEL ❑ 2. NON-FUEL PETROLEUM ❑ Ic. MIDGRADE UNLEADED ❑ 4. GASOHOL ❑ 99. OTHER ❑ 3. CHEMICAL PRODUCT COMMON NAME (from Hararidous Materials Inventory page) qq 1 CAS# (from Ha ardous Materials Inventory page) 442 ❑ 4. HAZARDOUS WASTE (Includes Used Oil) ❑ 95. UNKNOWN III. TANK CONSTRUCTION TYPE OF TANK ❑ L SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one item only) EXTERIOR MEMBRANE LINER ❑ 95. UNKNOWN ❑ 2. DOUBLE WALL ❑ 4. SINGLE WALL IN VAULT ❑ 99. OTHER TANK MATERIAL - primary tank ❑ L BARE STEEL ❑ FIBERGLASS / PLASTIC ❑ 5. CONCRETE ❑ 95. UNKNOWN 444 (Check one item only) ❑ 2. STAINLESS STEEL ❑ STEEL CLAD W/FIBERGLASS ❑ 8. FRP COMPTIBLE W/ 100% METHANOL REINFORCED PLASTIC (FRP) ❑ 99. OTHER TANK MATERIAL - secondary tank ❑ 1. BARE STEEL ❑ 3. FIBERGLASS/ PLASTIC ❑ 5. CONCRETE ❑ 95. UNKNOWN 445 (Check one item only ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD W/FIBERGLASS ❑ 8. FRP COMPTIBLE W/100% METHANOL REINFORCED PLASTIC (FRP) ❑ 10. COATED STEEL ❑ 99. OTHER ❑ 5. CONCRETE TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING ❑ 95. UNKNOWN 446 DATE INSTALLED 447 OR COATING E]99. OTHER (Check one item only) ❑ 2 ALKYD LINING ❑ 4 PHENOLIC LINING E]6 UNLINED (For local use only) OTHER CORROSION ❑ 1 MANUFACTURING CATHODIC ❑ 3 FIBERGLASS REINFORCED PLASTIC ❑ 95 UNKNOWN 448 DATE INSTALLED 449 PROTECTION IF APPLICABLE PROTECTION ❑ 4 IMPRESSED CURRENT ❑ 99 OTHER (Check one item only) ❑ 2 SACRIFICIAL ANODE (For local use only) SPILL AND OVERFILL YEAR INSTALLE450 TYPE (local use only) 451 OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 452 (Check all that apply) ❑ I SPILL CONTAINMENT ❑ 1 ALARM ❑ 3 FILL TUBE SHUT OFF VAL` ❑ 2DROPTUBE ❑ 2BALL ❑ 4EXEMPT ❑ 3 STRIKER PLATE FLOAT IV. TANK LEAK DETECTION (A description of the monitoring program shall be submitted to the local agency.) IF SINGLE WALL TANK (Check all that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 ❑ I VISUAL (EXPOSED PORTION ONLY) ❑ 5 MANUAL TANK GAUGING (MTG) (Check one item only) ❑ 2 AUTOMATIC TANK GAUGING (ATG) ❑ 6 VADOSE ZONE ❑ 1 VISUAL (SINGLE WALL IN VAULT ONLY) ❑ 3 CONTINUOUS ATG ❑ 7 GROUNDWATER ❑ 2 CONTINUOUS INTERSTITIAL MONITORING ❑ 4 STATISTICAL INVENTORY RECONCILIATION ❑ 8 TANK TESTING ❑ 3 MANUAL MONITORING (SIR) BIENNIAL TANK TESTING ❑ 99 OTHER V. TANK CLOSURE INFORMATION / PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED (YR/MO/DAY) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIALS 457 1 ❑ Yes ❑ No UPCF (12/99 revised)