COMPLIANCE INFO_1997-2006 - Laserfiche WebLink

Home Browse Search

UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 1 (Two pages per tank) Page_of TYPE OF ACTION ❑ 1,NEW PERMIT ❑ 4.AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430. (Cleckone ltemonly) ❑ 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE (Specify reason) (Specify reason) ❑ 8.TANK REMOVED BUSINESM (sn sFACt.ITYEorDBA-Doing Business As) 3, FACILITY ID: I I I I I TFh LOCATION WITHIN SITE(Optiona0 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.) TANK ID# 432• TANK MANUFACTUREREA/�t A)� 433. COMPARTMENTALIZED TANK ❑Yes o 434. V V V If"Yes,"complete one page for each compartment. DATE INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS 437 (YEAR/MO) ADDITIONAL DESCRIPTIO (Forkwaluseonly) �7 438. 11.TANK CONTENTS TANK USE 439• PETROLEUM TYPE 440. NTV MOTOR VEHICLE FUEL Sk0a. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (1 heckcd,completePetroleumType) [:1 1b. PREMIUM UNLEADED [3 3. DIESEL 06. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑Ic. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: ❑ 3. CHEMICALPRODUCT COMMON NAME(fi-oni Hazardous Materials Inventory page) 441. CASH(fi'omBazardousMaterials Inventory page) 442. ❑ 4. HAZARDOUS WASTE (Includes Used Oil) ❑ 95.UNKNOWN III.TANK CONSTRUCTION TYPEOFTANK ❑t. SINGLE WALL [13. SINGLE WALL WITH EXTERIOR ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. (Check one item only) MEMBRANE LINER [195. UNKNOWN DOUBLE WALL [14. SINGLE WALL IN A VAULT ❑99. OTHER TANK MATERIAL-primary tank CS I. BARESTEEL ❑3. FIBERGLASS/PLASTIC ❑5. CONCRETE ❑95.UNKNOWN 444. (Check one item only) ❑2. STAINLESS STEEL W. STEEL CLAD W/FIBERGLAS$ ❑8. FRP COMPATIBLE ❑99.OTHER: __ REINFORCED PLASTIC(PRP) W/100%METHANOL TANK MATERIAL-secondtuy tank ❑1. BARE STEEL [13. FIBERGLASS/PLASTIC ❑8. FRP COMPTIBLE W/I00%METHANOL e5.UNKNOWN 445. (Check one item only) ❑2. STAINLESS STEEL[14. STEEL CLAD W/FIBERGLASS [19. FRP NON-CORRODABLE JACKET [199.OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING 0 1.RUBBER LINED 3.EPDXY LINING 5.GLASS LINING 5.UNKNOWN 446. DATE INSTALLED 447. OR COATING [12.ALKYD LINING ❑4.PHENOLIC LINING ❑6.UNLINED [199.OTHER_ (Check one item only) OTHER CORROSION ❑I.MANUFACTURED CATHODIC 3.FIBERGLASS REINFORCED PLASTIC V95.UNKNOWN 448. DATE INSTALLED 449. PROTECTION PROTECTION ❑4.IMPRESSED CURRENT ❑99.OTHER (If A licable) ❑2.SACRIFICIAL ANODE SPILL AND OVERFIIJ Y R I TALLER 450. TYPE 451. OVERFILL PROTECTION E IPMENT: YEAR INSTALLED t (Check all that apply) SPILL CONTAINMENT 0 [-]1.ALARM _ 3.FILL TUBE SIIUTOFF VALVE Iq i DROP TUBE Z [12.BALL FLOAT_ ❑4.EXEMPT 3.STRIKER PLATE IV.TANK LEAK DETECTION (A description of the monitoring program shall be submitted to the local agency.) IFSINGL.EWALL TANK 453. IF DOUBLE WALL TANK OR TANK WITH BLADDER 454. (Check all that apply) (Check one item only) ❑1. VISUAL(EXPOSED PORTION ONLY) ❑5.MANUAL TANK GAUGING(MTG) ❑1.VISUAL(SINGLE WALL W VAULT ONLY) ❑2.AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE kP.CONTINUOUS INTERSTITIAL MONITORING ❑3.CONTINUOUS ATG ❑7.GROUNDWATER ❑3.MANUAL MONITORING ❑4. STATISTICAL INVENTORY RECONCILIATION ❑8.TANK TESTING (SIR)+BIENNIAL TANK TESTING ❑99. OTHPR V.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;? 452 _ gallons ❑Yes ❑ No UPCF hwfwre-b(1/99)-114 Ilttp://www.iinidGcs.org Rev.02/16/00