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_I_of_2 TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 4.AMENDED PERMIT ❑ S.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430. (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE (Specify reason) (Specify reason) ❑ 8.TANK REMOVED BUSINESS AME(Sane as FACILITY NAME or DBA-Doing Business As) 3, 1 FACILITY ID: 1. LOCATION WITHIN SITE(optional) 431. I.TANK DESCRIPTION (A scaled plot plan with the location of the UST s stem including buildings and landmarks shall be submitted to the local agency.) TANK ID# 432. TANK MANUFACTURERy (P 433• COMPARTMENTALIZED TANK F1 Yes ® No 434. I`��v (/ If"Yes,"complete one page for Inch compartment. DATE INSTALLED 435. TANK CA ACITY IN GALLONS 436• NUMBER OF COMPARTMENTS 437 (YEAR/MO) AV ) ADDITIONAL DESCRIPTION(For localuseonly) v J 438. 11.TANK CONTENTS TANK USE 439• PETROLEUM TYPE 440. kft I. MOTOR VEHICLE FUEL la. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL recked,complete Petroleum Type) (b, PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑le. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER:_ ❑ 3. CHEMICAL PRODUCT COMMON N AM E (fiom Hazardous Materials Inventorypage) 441. CAS#(from 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 EXTERIOR ❑S. SINGLE WALL WITH INTERNAL BLADDER SYS'11M 443• (Check one item only) MEMBRANE LINER ❑95. UNKNOWN 0. DOUBLE WALL F-1-4. SINGLE WALL IN A VAULT ❑99. OTHER TANK MATERIAL-primary tank ❑1. BARE STEEL ❑3. FIBERGLASS/PLASTIC ❑5. CONCRETE ❑95.UNKNOWN 444. (Check one item only) ❑2. STAINLESS STEEL4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE El 99,OTHER: REINFORCED PLASTIC(FRP) W/100%METHANOL TANK MATERIAL-secondary tank [11. BARE STEEL ❑3, FIBERGLASS/PLASTIC [18. FRP COMPTIBLE W/100%METHANOL ®95.UNKNOWN 445. (Check one item only) [12. STAINLESS STEEL❑4. STEEL CLAD W/FIBERGLASS [19. FRP NON-CORRODABLE JACKET ❑99.OTHER_ REINFORCED PLASTIC(FRP) ❑10. COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING ❑1.RUBBER LINED [:13,EPDXY LINING ❑5.GLASS LINING ®95.UNKNOWN 446. DATE INSTALLED 447. OR COATING ❑2.ALKYD LINING ❑4,PHENOLIC LINING ❑6.UNLINED ❑99.OTHER (Check one item only) OTHER CORROSION ❑ I.MANUFACTURED CATHODIC ❑3.FIBERGLASS REINFORCED PLASTIC ®95.UNKNOWN 448. DATE INSTALLED 449. PROTECTION PROTECTION ❑4.IMPRESSED CURRENT ❑99.OTHER (If Applicable) 2.SACRIFICIAL ANODE SPILL AND OVERFILL YEAR NST ALLED 450. TYPE 451. OVERFILL PROTECTION E MENT: YEAR INSTALLED (Check all that apply) SPILT.CONTAINMENT ❑ I.ALARM 3.F . ILL TUBE SHUT OFF VALVE'I@5 . ROPTUBE _ ❑2.BALL FLOAT__ ❑4.EXEMPT 3.STRIKER PLATE IV.TANK LEAK DETECTION (A description of the monitoring program shall be submitted to the local agency.) IF SINGLE WALL TANK 453. IF DOUBLE WALL TANK OR TAMC 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 IN VAULT ONLY) ❑2.AUTOMA'T'IC TANK GAUGING(ATG) ❑6.VADOSE ZONE P2.CONTINUOUS INTERSTITIAL MONITORING [13. CONTINUOUS ATG ❑7.GROUNDWATER ❑3.MANUAL MONITORING ❑4. STATISTICAL INVENTORY RECONCILIATION ❑8.TANK TESTING (SIR)i BIENNIAL TANK TESTING ❑99.OTHER 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 INERTMATERIAL? 457. gallons ❑Yes ❑ No UPCT hwfwrc-b(1/99)-1/4 http://www.tDti(Ioes.Org Rev.02/16/00