COMPLIANCE INFO_1997-2012 - Laserfiche WebLink

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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS =TANK PAGE I (two pages per tank) Page—of TYPE OF ACTION ❑I NEW SITE PERMIT ❑ 4 AMENDED PERMIT*5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE ❑ 7 PERMANENTLY CLOSED ON SITE (Check one item only) [1cMOVED 430 3 RENEWAL PERMIT (Specify reason-for local use only) (Specify reasor.-for local tue only) ❑ 8 TANK REI FACILITY ID: - BU INES AME as F CILITY IE or DBA-Doing Business As) 3 / 431 LOCATION WITHIN SITE(optional) I.TANK DESCRIPTI t (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local cy.) agen TA KID# a32 TANK Mr1NUFACTURER COMPARTMENTAL[ZEDTRNK ❑Yes No 434 "� ,� If"Yes-,complete one page for each compartrnent. ,) G), 436 NUMBER OF COMPARTMENTS 437 ATE INSTALLED(YEAR/MO) 35 TANK CAPACITY IN GALLONS _y 438 ADDITIONAL DESCRIPTION(For local use only) II.TANK CONTENTS 440 TANK USE 439 PETROLEUM TYPE 1. MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED ❑2. LEADED ❑5. FUEL 6. AVIATION FUEL (if mvked complete PetroleumType) PREMIUM UNLEADED ❑3. DIESEL ❑ ❑lc. MIDGRADE UNLEADED ❑4. GASOHOL C]99.OTHER [12. NON-FUEL PETROLEUM 44z ❑3. CHEMICAL PRODUCT COMMON NAME (from Hazardous Materials Inventory,page) 4(I CAS#(from Hacardow Materials Inventory page) ❑4. HAZARDOUS WASTE (Includes Used Oil) ❑95.UNKNOWN III. TANK CONSTRUCTION - a(3 TYPEOFTANK I. SINGLE WALL 3. SINGLE WALL WITH 5 .SINGLE WALL WITH INTERNAL BLADDER SYSTEM EXTERIOR NIEMBRANE LINER ❑95.UNKNOWN (Check one item only) DOUBLE WALL ❑4. SINNLE WALL IN VAULT ❑99. OTHER TANK MATERIAL-primary tank 1. BARE STEEL FIBERGLASS/PLASTIC 5. CONCRETE 95' UNKNOWN 444 (Check one item only) 02, STAINLESS STEEL g4. STEEL CLADW/FIBERGLASS FRP COMPTIBLEW/100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) 445 TANK MATERIAL-secondary tank I. BARE STEEL 3. FIBERGLASS/PLASTIC CONCRETE 95. UNKNOWN (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASSYIO.COATEDSTEEL . FRP COMPTIBLE W/100%h1ETHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) [:15. CONCRETE 447 TANK INTERIOR LINING ❑I.RUBBER LINED 3.EPDXY LINING 5.GLASS LINING 95.UNKNOWN a46 DATE INSTALLED OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING ❑6 UNLINED 099 OTHER (For local use only) (Check one item only) 448 DATE INSTALLED 449 OTHER CORROSION ❑1 MANUFACTURED CATHODIC ❑3 FIBERGLASS URRENT CED PLASTIC 0 999 O KNOWN HER PROTECTION IF APPLICABLE PROTECTION C14 IMPRESSED C (For local use only) (Check one item only) ❑2 SACRIFICIAL ANODE 452 SPILL AND OVER YEAR INSTALLED 450 TypE(local use only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED ❑I ALARM TUBE SHUT OFF VALVE (Check all that apply) [3 I SPILL CONTAINMENT T 4 EXEMP DROP TUBE ❑Z BALL FLOAT ❑ ❑3 STRIKER PLATE local gency.) IV.TANK LEAK DETECTION(A description ofthemonitoring pi DOUBLE WALL Tshall be submitted to eANKaOR TANK WITH BLADDER 454 453 IF SINGLE WALL TANK(Check all that apply) (Check one item only) ❑1 VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MTG) ❑1 VISUAL(SINGLE WALL IN VAULT ONLY) ❑2 AUTOMATIC TANK GAUGING(ATG) ❑ 6 VADOSE ZONE ONTINUOUS INTERSTITIAL MONITORING ❑3 CONTINUOUS ATG ❑7 GROUNDWATER ❑3 MANUAL MONITORING ❑4 STATISTICAL INVENTORY RECONCILIATION ❑8 TANK TESTING (SIR) BIENNIAL TANK TESTING ❑99 OTHER t IV.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE 457 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH WEiR-7,lrtATERIAL? ESTIMATED DATE LAST USED(YR/MO/DAY) gallons ❑Ye LJ No UPCF(12/99 revised) 10 Formerly SWRCB Form B