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Stage I Type <br />Stage 11 type <br />0 <br />2016 Equipment Survey <br />Tank # <br />Material of <br />Siphon Bar? <br />Corrosion <br />Yes or No <br />Construction <br />CAS = Healy Clean Air <br />Protection <br />2PT= Two Point <br />DWF = DW Fiberglass Does this tank dispense thru <br />Separator <br />Order <br />SWF = SW Fiberglass <br />SWS = SW Steel <br />the use of o Siphon Bar 8 <br />IC = Impressed Currant <br />per tank <br />WRP = Wrapped <br />are the connections to each <br />tank visible? <br />SA <br />SAC = Sac c Anode <br />Site # �-G� <br />Address 2� T <br />G� i <br />L.%Jo <br />FLX = Flexible <br />SNV = Siphon, wri. not visible <br />UNK=Unknown <br />- <br />NK = Unknown <br />NA = No Siphon <br />2 <br />UST Monitoring System <br />3 <br />Date O Q 0-7 t (o Contractor name / Tech name <br />4 <br />5 <br />Petroleum Storage Tanks <br />6 <br />Tank # <br />Product Capacity <br />UST.,AST <br />AST Impact Barrier <br />Split Tank <br />Striker Plate <br />Auxtlary <br />Manlfolded t Siphoned <br />R = Regular Unleaded Nominal Gallons <br />What type of impact barrier is <br />Order <br />per tank <br />M = Mid Grade Nearest (000) <br />P = Premium <br />UST = Underground <br />Tank <br />present? manic iw Usra <br />�iV° ) <br />6 = Bogards F = Fencing <br />Split Tank TSP =Tank Striker Plate <br />DSP = DropTube Striker Plate <br />Auxilary Tank <br />Manitokled / Siphoned Tank <br />monitor <br />D =Diesel (nearaA birth for <br />Cartes <br />AST = Aboveground <br />I = Inside Service Bays <br />Yes No <br />N = None <br />W = Waste OR teas than <br />500 aallan 1 <br />Tank <br />L = Located away from traffic <br />or <br />LINK = Unknown <br />Yes or No <br />(if $o, to what other tank) <br />H = Heating Oil <br />N = AST present, no barrier <br />r'C D/OGG <br />J ST- <br />(A- <br />100 <br />L) <br />tJ O <br />7-, NO <br />2 <br />kelmNO <br />Q <br />3 <br />NO <br />Z <br />4 <br />YES <br />5 <br />YES NO <br />6 <br />YES NO <br />Petroleum Storage Tanks <br />Vent Caps <br />Tank # <br />Material of Construction <br />Corrosion <br />Protection <br />Protection <br />Lined Tank Interstitial <br />Remote Fill OR / WA / CA <br />Manufacturer <br />Model # <br />Selo <br />Onl <br />D WF = Ooubtetvag Fiberglass <br />Lined <br />SWF - Singlewall Fiberglass <br />DWS = Doublewail Steel <br />IC = Impressed Current <br />Tank <br />B = Brine <br />Does the Does the LIST Ftl7 <br />remote fig <br />DWS= Singkwvaa Steel <br />oWSP = Ooublewatl STIP <br />SAC =Sac Anode <br />NM =Nan-meta6ic <br />uakUW. u.awe D = 0 <br />=,y rear Dry <br />VC =Vacuum <br />Remota Fill <br />have a spill Riser have a <br />P <br />bucket? tethered <br />OPW <br />H =Husky <br />Write Model Number <br />SWSP = Singiewall STIP <br />UNK = Unknown <br />Mere N = None <br />Yes or No <br />grounding cable? <br />M = Morrison Bras <br />in space proved <br />CLD = Steel Clad w/Fibergiass <br />LINK = Unknown <br />Yes or No <br />YES or NO <br />Yes or No <br />UNK= Unknown <br />or NA <br />�UN1K=Unknown <br />f <br />2 <br />3 <br />4 <br />5 <br />nrj <br />q <br />1 2016 <br />6 <br />Stage I Type <br />Stage 11 type <br />Product Piping <br />F— pur— <br />Tank # <br />Material of <br />Siphon Bar? <br />Corrosion <br />Yes or No <br />Construction <br />CAS = Healy Clean Air <br />Protection <br />2PT= Two Point <br />DWF = DW Fiberglass Does this tank dispense thru <br />Separator <br />Order <br />SWF = SW Fiberglass <br />SWS = SW Steel <br />the use of o Siphon Bar 8 <br />IC = Impressed Currant <br />per tank <br />WRP = Wrapped <br />are the connections to each <br />tank visible? <br />SA <br />SAC = Sac c Anode <br />monitor <br />Steel <br />SV= Siphon, con. visible <br />= <br />FLX = Flexible <br />SNV = Siphon, wri. not visible <br />UNK=Unknown <br />- <br />NK = Unknown <br />NA = No Siphon <br />2 <br />UST Monitoring System <br />3 <br />4 <br />5 <br />6 <br />Stage I Type <br />Stage 11 type <br />Pressure Witj — <br />F— pur— <br />Does Monitor <br />have a Printer <br />(nozzle type) <br />Write Model Number in space provided <br />W^te Software Verson <br />Yes or No <br />BL = Balance <br />CAS = Healy Clean Air <br />space provided <br />2PT= Two Point <br />VA = Vacuum Assist <br />Separator <br />PT= PHIL TITE <br />CP = Coaxial Poppeted <br />VST = Vapor Systems Tech <br />VR = VR Carbon Canister <br />DPW = OPW VR <br />CN = Coaxial Non•Poppeted <br />HEVR = Healy w/ EVR <br />VST = VST Vapor Processor <br />NA = No EVR <br />NA = No Stage it <br />NA = Outside of California <br />2 FIF <br />15 L-- <br />C A S 1171 <br />- <br />Vapor Pot i7o.. <br />the site have a vapor pot (drop out tank)? Yes or No <br />UST Monitoring System <br />Printer <br />Manufacturer <br />Model Number <br />Software Ver. <br />Does Monitor <br />have a Printer <br />VR = Veedar Root <br />Write Model Number in space provided <br />W^te Software Verson <br />Yes or No <br />None <br />space provided <br />` /NNA�= <br />v <br />.g+ <br />IL� <br />gin <br />/ d� <br />i—dotn4aota Page 1 of 4 <br />RZ <br />