COMPLIANCE INFO_1995-2004 - Laserfiche WebLink

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UNIFIED PROGRAM CONSOLIDATED FORM �C�titi �� ok TANKS UNDERGROUND STORAGE TANkS -TANK PAGE 1 (two pages per tank) NN Page of> _.PE OF ACTION r 1. NEW SITE PERMIT r 4. AMENDED PERMIT r 5. CHANGE OF INFORMATION) r 6. TEMPORARiYY SITE CLOSURE (Check one item only) F2. NEW OPERATOR , r 7. PERMANENTLY CLOSED ON SITE F 3. RENEWAL PERMIT (Specify,reason-for local use only) (Specify change for local use only) r 8. TANK REMOVED 430 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID# 1 Country Club Shell LOCATION WITHIN SITE(Optional)431 2575 Country Club Blvd, Stockton, CA 95204 L 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# S 4 705432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK r Yes X No 434 te3;0i 136144-Wasl1& Owens Corning If AYes_,complete one page for each compartment. DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 1987 550 One Compartment ADDITIONAL DESCRIPTION(For local use only) 438 II.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 Fl. MOTOR VEHICLE FUEL --,-,Fla. REGULAR UNLEADED r 2. LEADED r 5. JET FUEL (If marked,complete Petroleum Type) r lb. PREMIUM UNLEADED r 3. DIESEL r 6. AVIATION FUEL F 2. NON-FUEL PETROLEUM r Ic. MIDGRADE UNLEADED r 4. GASOHOL r 99. OTHER r 3. CHEMICAL PRODUCT COMMON NAME'(lrom Hazardous Materials Inventory page)441 CAS#(from Hazardous Materials Inventory page) 442 X 4. HAZARDOUS WASTE(Includes Used Oil) USED OIL F 95. UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK r 1. SINGLE WALL r 3. SINGLE WALL WITH r 5. SINGLE WALL-WITH INTERNAL BLADDER SYSTEM 443 ck one item only) X 2. DOUBLE WALL EXTERIOR MEMBRANE LINER r 95. UNKNOWN F 4. SINGLE WALL IN A VAULT F ss. OTHER TANK MATERIAL-primary tank r 1. BARE STEEL X 3. FIBERGLASS/PLASTIC r 5. CONCRETE r 95. UNKNOWN 444 (Check one item only) r 2. STAINLESS STEEL r 4. STEEL CLAD W/FIBERGLASS r 8. FRP COMPATIBLE W1100%METHANOL r 99. OTHER REINFORCED PLASTIC FRP TANK MATERIAL-secondary r 1. BARE STEEL X 3. FIBERGLASS/PLASTIC r 8. FRP COMPATIBLE W/100%METHANOL r 95. UNKNOWN 445 tank r 2. STAINLESS STEEL r 4. STEEL CLAD W/FIBERGLASS r 9. FRP NON-CORRODIBLE JACKET r 99. OTHER (Check one item only) REINFORCED PLASTIC(FRP) I-10, COATED STEEL F 5. CONCRETE TANK INTERIOR LINING r 1. RUBBER LINED r 3. EPDXY LINING r 5. GLASS LINING r 95. UNKNOWN446 DATE INSTALLED 447 OR COATING r 2. ALKYD LINING r 4. PHENOLIC LINING X 6. UNLINED r 99. OTHER Check one item only) For local use only) OTHER CORROSION r 1. MANUFACTURED X 3. FIBERGLASS REINFORCED PLASTIC r 95. UNKNOWN 448 DATE INSTALLED 449 PROTECTION IF APPLICABLE CATHODIC PROTECTION r 4. IMPRESSED CURRENT r 99. OTHER (Check one item only) (For local use only) r 2. SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED TYPE(For local use only)451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 450 (Check all that apply) X 1. SPILL CONTAINMENT 1998 r 1. ALARM r 3. FILL TUBE SHUT OFF VALVE r 2. DROP TUBE X 2. BALL FLOAT r 4. EXEMPT X 3. STRIKER PLATE _1987_ IV. TANK TEAK DETECTION (A description of the monitoring program shall be submitted td the tical agency.) IF SINGLE WALL TANK(Check all that apply): 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER(Check one item only): 454 r 1, VISUAL(EXPOSED PORTION ONLY) r 5. MANUAL TANK GAUGING(MTG) r 1. VISUAL(SINGLE WALL IN VAULT ONLY) r 2. AUTOMATIC TANK GAUGING(ATG) r 6. VADOSE ZONE X 2. CONTINUOUS INTERSTITIAL MONITORING r 3. CONTINUOUS ATG r 7. GROUNDWATER r 3. MANUAL MONITORING T_ 4. STATISTICAL INVENTORY RECONCILIATION(SIR)r r 8, TANK TESTING BIENNIAL TANK TESTING r 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 MATERIAL? 457 gallons r Yes r No 6