COMPLIANCE INFO_2006-2015 - Laserfiche WebLink

Home Browse Search

4/ IFIED PROGRAM CONSOLIDATED7-77; UNDERGROUND STORAGE TANK /! OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections 1,II,III,IV,and IX below) 430 ❑ I.NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430a I DATE EXISTING UST DISCOVERED: 4306 I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) I BUSINESS NAME Same as FACILITY NAME or DBA-Doing Busin As) 3 ICM U�;3 BUSINE 5ITEAD ESS C CEMd4^) 0 j, Io3 C[Ty � jO too II.TANK DESCRIPTION T TANK[ 7 "TNI;,� ,`>� 432 TANK MANUFACTU�R/E�R�J 433 TANK CONFIGURATION: THIS TANK IS 434 A STAND-ALONE TANK ❑2.ONE IN A COMPARTMENTED UNIT. Conipletc one page for each coapntmea in the unit. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 D©O III.TANK USE AND CONTENTS TANK USE SQ&MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ lc.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(inches Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§252815(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 439a CONTENTS PETROLEUM: la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ ib.PREMIUM UNLEADED 440 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ S.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (S i ): 440a NON-PETROLEUM:❑7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify), 4496 N. TANK CONSTRUCTION TYPE OF TANK 5f I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT 0 1.STEEL El 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+ AL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ L.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NO C195.UNKNOWN ❑99.OTHER(Specify). 445a OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED .DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE R 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION(23 CCR§2636(ax3)1 458 PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL 1&4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL rX 2.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER I FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT IRI.STEEL 0 4 FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e VENT SECONDARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464f VR PRIMARY CONTAINMENT I.STEEL ❑ 4.FIBERGLASS ❑ 10.91GID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464g 4641al VR SECONDARY CONTAINMENT IR I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464h 464ht VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL IN 2.DOUBLE WALL ❑ 90.NONE 464L RISER PRIMARY CONTAINMENT I.STEEL ❑ 4.FIBERGLASS 0 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464} 4641I RISER SECONDARY CONTAINMENT I.STEEL ❑ 4.FIBERGLASS 0 10.RIGID PLASTIC 0 90.NONE❑ 99.OTHER(Specify) 464k 464kl FILL COMPONENTS INSTALLED 9 1.SPILL BUCKET ❑ 3.STRIKER PLATEBOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451a•c VII.UNDER DISPENSER CONTAINMENT(UDC), CONSTRUCTION TYPE ❑ T.SINGLE WALL (81.2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL 19 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ ".OTHER(Specify) 469b•c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION .�{ 2.SACRIFICIAL ANODF(S) ❑ 4.IMPRESSED CURRENT b.ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION: i certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true,accurate, and in full compliance w'th legal requirements. APPLICANT SIGNATURE DAA 7 /Z� �O . 470. APPLICANT NAME(print)�© S r r� 471. APPLICANT TITLE 47-- UPCF UST-B-1/2 Rev.(12!2007)