COMPLIANCE INFO_2002-2009 - Laserfiche WebLink

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UNIFIED PROGRAM CONSOLIDATED FORP V TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 1 a (Two pages per tank) Page_of TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 4.AMENDED PERMIT 91 5.CHANGE OF INFORMATION [_1 6. 6.PERMANENTLY TEMPORA PNTL AN CLOSED OCLOSN SITE 430. (Check one item only) ❑ 3.RENEWAL PERMIT ❑ S.TANK REMOVED (Specify reason) (Specify reason) . BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As 3. FACILITY ID: LOCATION THIN SI (optional) � 5 31. TANK DESCRIPTION i`�E��Nt� G H (A scaled plot plan with the location of the UST system including buildings and landmarksOMPARTMENTALIZED TTANK O``� V`ll be submitted to t1le local C4 TANK ID# 432. TANK MANUFACTURER ^ 12 If"Yes,"conpkte one page for each compartment. rl It 435. . 436. MPARTMENTS 437. DATEfNSTA LED TANK CAPACITY IN GALLONS NUMBER OF CO (YEAR/MO) !�, �e cJ 1V 438. AD I A ESCRIPTION(For local use only) II.TANK CONTENTS a40. TANK USE 439. PETROLEUM TYPE (( 1. MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED [12. LEADED ❑S. JET FUEL (If checked,conVIcte Petroleum Type) ()fib. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑1 c. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER 441. inventory page) 442. ❑ 3. CHEMICAL PRODUCT Inventory page) CAS#(Sem Haz�eus Materials Invento COMMON NAME (from Hazardous Materials Invento e) ❑ 4. HAZARDOUS WASTE (Includes Used Oil) ❑ 95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK ❑1. SINGLE WALL [:13. SINGLE WALL WITH EXTERIOR ❑5. SINGLE WALL��TTH INTERNAL BLADDER SYSTEM 443. (Check one item only) MEMBRANE LINER ❑95. UNKNOWN 2. DOUBLE WALL ❑4. SINGLE WALL IN A VAULT ❑99. OTHER 444 TANK MATERIAL-pr many tank ❑1. BARE STEEL 3. FIBERGLASS/PLASTIC [:15. CONCRETE ❑95.UNKNOWN (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS [18. FRP COMPATIBLE ❑99.OTHER: REINFORCED PLASTIC FRP W/100%METHANOL TANK MATERIAL-secondary tank ❑1. BARE STEEL ❑3. FIBERGLASS/PLASTIC ❑S. FRP CO MPTIBLE W 100°/.METHANOL 95.UNKNOWN aa5. (Check one item only) ❑2. STAINLESS STEEL[14. STIEPEIFCLAD ORCED PLASTIC FA (FRP) ❑10. COATED STEEL JACKET ❑99.OTHER [15. CONCRETE _ TANK OR COATING OR LINING 2_AYD[MNG ❑4.PHENOLIC LINING 6.UNLINED LINING ❑99.0 Owl �6' DATE INSTALLED 447. Check one item only) OTHER CORROSION ❑1.MANUFACTURED CATHODIC 3.FIBERGLASS REINFORCED PLASTIC ❑95.U'K KNOWN aas. DATE INSTALLED 449. PROTECTION PROTECTION ❑4.IMPRESSED CURRENT ❑99.OTHER If A licable ❑2.SACRIFICIAL ANODE SPILL AND OVERFILL YAR INSTALLE)AA 450. TYPE 451. OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED a52. 1.SPILL CONTAINMENT f 11( ALARM ❑3.FILL TUBE SHUT OFF VALVE (Check all that apply) ( 2.BALL FLOAT_ ❑4.EXEMPT ❑2.DROP TUBE ❑3.STRIKER PLATE IV.TANK LEAK DETECTION (A description of the monitoring program shall be submitted to the local agency.) 45a 4s3. IF DOUBLE WALL TANK OR TANK WITH BLADDER IF SINGLE WALL TANK (Check one item only) (Check all that apply) 5.MANUAL TANK GAUGING(MT G) ❑1.VISUAL(SINGLE WALL IN VAULT ONLY) ❑1. VISUAL(EXPOSED PORTION ONLY) ❑ ❑2. AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE �.CONTLNL'OUS LNTERSTITIAL MONITORING ❑3.CONTINUOUS ATG ❑7.GROUNDWATER ❑3.MANUAL MO NTIORING ❑4. STATISTICAL INVENTORY RECONCILIATION ❑8.TANK TESTING (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 WI❑T YINER❑T MATERIAL? as7. No gallons UPCF hwfwrc-b(1/99)-1/4 http://www.unidocs.org Rev.02/16/00 I