COMPLIANCE INFO_1999-2005 - Laserfiche WebLink

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UNIFIED PROGRAM CONSOLIDATED FORM ` Ate' 3N?!i�P3TANKS UNDERGROUND STORAGE TANKS - TANK PAGE I O 1 L 3 h (two pages per tank) TYPE OF ACTION 111 NEW SITE PERMIT ❑ 4 AMENDED PERMIT (/ Page of ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Check one item only) ❑ 7 PERMANENTLY CLOSED ON SITE, ❑ 3 RENEWAL PERMIT (Specify reason-for local use only) (Specify reason-for local use only) ❑ 8 'TANK REMOVED 430 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) FACILITY ID: 1 USA GASOLINE#3 3 LOCATION WITHIN SITE(optional) 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.) tADDITIONAL K ID# 43z TANK MANUFACTURER 433 COMPARTMENTALIZED TANK ❑Yes C6�y_6f�� ® No 434 ( 7 TRUSCO If"Yes".complete one page for each compartment. E INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 8 14000 DESCRIPTION(For local use only) 438 II.TANK CONTENTS TANK USE 439 PETROLEUM TYPE MOTOR VEHICLE FUEL ®la. REGULAR UNLEADEDtut ❑2. LEADED ❑5. JET FUEL (if marked complete Petroleum Type) ❑1 b. PREMIUM UNLEADED ❑3. DIESEL 06. AVIATION FUEL ❑2 NON-FUEL PETROLEUM ❑Ic. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER ❑3. CHEMICAL PRODUCT COMMON NAME (from Hazardous Materials inventory page) 441 CAS#(front Hazardous Materials Inventory page) 442 ❑4. HAZARDOUS WASTE (Includes Used Oil) ❑95.UNKNOWN III. TANK CONSTRUCTION TYPE OF TANK ❑1. SINGLE WALL 0 3. SINGLE WALL WITif ❑5. SINGLE WALL WITH INTERNAL BLADDER SYS'ITM 443 (Check one item only) EXTERIOR MEMBRANE LINER ❑95. UNKNOWN ®2. DOUBLE WALL [34. SIGNLE WALL IN VAULT ❑99. OTHER TANK MATERIAL-primary tank R9 1. BARE STEEL ❑3. FIBERGLASS/PLASTIC ❑5. CONCRETE [:195. UNKNOWN 444 (Check one item only) ❑2. STAINLESS STEEL [34. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPTIBLE W/100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) TANK MA'T'ERIAL-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 ❑99.OTHER REINFORCED PLASTIC(FRY) ❑10.COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING I.RUBBER LINED0 3.EPDXY LINING LJ 5.GLASS LINING 95.UNKNOWN 446 DATE INSTALLED 447 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING ®6 UNLINED (Check one item only) ❑99 OTHER (For local use otdy) OTHER CORROSION ❑1 MANUFACTURED CATHODIC ❑3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN 448 448 PROTECTION IF APPLICABLE PROTECTION ❑4 IMPRESSED CURRENT ❑99 OTHER (Check one item only) ❑2 SACRIFICIAL ANODE (For local use only) SPILL AND OVERFILL YEAR INSTALLED 450 TYPE(local use only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Check all that apply) ®1 SPILL CONTAINMENT 1998 ❑I AI-ARM ®3 FILL TUBE SHUT OFF VALVE ®2 DROP TUBE 1998 ❑2 BALL FLOAT ❑4 EXEMPT ®3 STRIKER PLATE 1998 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 [F DOUBLE WALL TANK OR TANK WITH BLADDER 454 (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 ®2 CONTINUOUS INTERSTITIAL MONITORING ❑3 CONTINUOUS ATG ❑7 GROUNDWATER ❑3 MANUAL MONITORING ❑4 STATISTICAL INVENTORY RECONCILIATION ❑8 TANK TESTING (SIR) BIENNIAL'TANK TESTING ❑99 OTHER IV.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 ❑Yes ❑ No UPCF(1/99 revised) Formerly SWRCB Form B