COMPLIANCE INFO_1996-2005 - Laserfiche WebLink

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IFIED PROGRAM CONSOLIDATED FORMIM TANK: TA0506252 PR#: PRO231350 UNDERGROUND STORAGE TANKS -TANK PAGE 1 FAC#: FA0003690 (two pages per tank) o�ll�v TYPE OF ACTION E] Page4 of7 1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE / f (Check only item only) ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT01100M-Mh,i"OV EMI-7-729120M ❑8 TANK REMOVED 430 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) FACILITY ID: PR#: 1 LODI FOOD&LIQUOR* 3 FA0003690 PR0231350 LOCATION WITHIN SITE(Optional) 1225 W LOCKEFORD ST,LODI 431 PHONE 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.) TANK ID# Tank#: 5 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK ❑Yes ❑No 434 TA0506252 MODERN WELDING If"Yes",complete one page for each compartment. DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 10,000 ADDITIONAL DESCRIPTION(For local use only) 438 II.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 ® t.MOTOR VEHICLE FUEL 0 la.REGULAR UNLEADED ❑ 2.LEADED ❑ 5.JET FUEL (If marked complete Petroleum Type) ❑ ib.PREMIUM UNLEADED ❑ 3.DIESEL ❑ 6.AVIATION FUEL ❑ 2.NON-FUEL PETROLEUM ❑ la MIDGRADE UNLEADED ❑4.GASOHOL ❑ 99.OTHER ❑ 3.CHEMICAL PRODUCT COMMON NAME(from Hazardous Materials Inventory page) 441 CAS#(Gone Hazardous Materials Inventory page) 442 ❑ 4.HAZARDOUS WASTE (Includes Used Oil) ❑ 95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ❑ 3.SINGLE WALL WITH ❑ 5.SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one item only) EXTERIOR MEMBRANE LINER 95.UNKNOWN ®2.DOUBLE WALL ❑ 4.SINGLE WALL IN VAULT ❑ 99.OTHER TANK MATERIAL-primary tank ❑ 1.BARE STEEL ❑ FIBERGLASS/PLASTIC ❑ 5.CONCRETE ❑ 95.UNKNOWN 444 (Check one item only) ❑ 2.STAINLESS STEEL ® STEEL CLAD W/FIBERGLASS ❑ 8.FRP COMPTIBLE W/100%METHANOL REINFORCED PLASTIC(FRP) ❑ 99.OTHER TANK MATERIAL-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 REINFORCED PLASTIC(FRP) ❑ 10.COATED STEEL ❑ 99.OTHER ❑ 5.CONCRETE TANK INTERIOR LINING ❑ RUBBER LINED 3EPDXY LINING I. ❑ . 447 OR COATING ❑ 5.GLASS LINING ❑X 95.UNKNOWN aa6 DATE INSTALLED (Check one item only) ❑2 ALKYD LINING ❑ 4 PHENOLIC LINING ❑ 6 UNLINED ❑ 99.OTHER (For local use only) OTHER CORROSION ❑ I MANUFACTURING CATHODIC X 3 FIBERGLASS REINFORCED PLASTIC449 PROTECTION IF APPLICABLE PROTECTION ❑ ❑ 95 UNKNOWN 448 DATE INSTALLED (Check one item only) F] 4 IMPRESSED CURRENT ❑ 99 OTHER ❑2 SACRIFICIAL ANODE (For local use only) SPILL AND OVERFILL YEAR INSTALLE450 TYPE(local use only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 1,996.00 (Check all that apply) iSPILL CONTAINMENT ❑ 1 ALARM 3 FILL TUBE SHUT OFF VAL` 01.4do DROPTUBE ❑ 3 STRIKER PLATE ❑ 2 BALL 4 EXEMPT ❑ FLOAT 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 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 ❑ I VISUAL(EXPOSED PORTION ONLY) ❑ 5 MANUAL TANK GAUGING(MTG) (Check one item only) ❑ 2 AUTOMATIC TANK GAUGING(ATG) ❑ 6 VADOSE ZONE ❑ I VISUAL(SINGLE WALL IN VAULT ONLY) ❑ 3 CONTINUOUS ATG ❑ 7 GROUNDWATER ®2 CONTINUOUS INTERSTITIAL MONITORING ❑ 4 STATISTICAL INVENTORY RECONCILIATION ❑ 8 TANK TESTING (SIR)BIENNIAL TANK TESTING ❑3 MANUAL MONITORING ❑ 99 OTHER V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) ass ESTIMATED QUANTITY OF SUBSTANCE REMAINING a56 TANK FILLED WITH INERT MATERIAL? 457 ❑Yes ❑ No UPCF(12/99 revised)