COMPLIANCE INFO_1999-2001 - Laserfiche WebLink

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� r ' UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 1 (two pages per tank) ��/ Page of TYPE OF ACTION (M 1.NEW SITE PERMIT ❑ 4. AMENDED PERMIT 5. CHANGE OF INFORMATION) ❑ S. TEMPORARY SITE CLOSURE (Check one item only) „'B!J'U V L1� L � ! ❑ 7. PERMANENTLY CLOSED ON SITE ❑3.RENEWAL PERMIT (Specify reason-for local use only) (Specify change-for local use only) 1 ❑ S. TANK REMOVED 430 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) FACILITY ID K 1 n y T+� LOCATION WITHIN SITE(Optionaq Fd 431 1.TANK DESCRIPTION TANK 10 0 TANK MANUFACTURER COMPARTMENTALIZED TANK Yes ❑ No r p � If'Yes*.complete one page for each compartment. DATE INSTA ED(YEAR/MO, TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS ADDITIONAL DESCRIPTION(Forlocal use only) 11.TANK CONTENTS TANK USE 432 PETROLEUM TYPE 21-, MOTOR VEHICLE FUEL ❑1a. ULAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL (If marked,complete Petroleum Type) tb. PREMIUM UNLEADED ❑ 3. DIESEL ❑ 6. AVIATION FUEL ❑ 2. NON-FUEL PETROLEUM ❑1c. MIDGRADE UNLEADED ❑ 4. GASOHOL ❑99. OTHER ❑ 3. CHEMICAL PRODUCT CAS S(from Hazardous Materials Inventory page) COMMON NAME(from Hazardous Materials Inventory page) Cl 4. HAZARDOUS WASTE(Includes Used Din El 95- U8KNOWN 111.TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM (Check one item only) DOUBLE WALL EXTERIOR MEMBRANE LINER ❑95. UNKNOWN ❑ 4. SINGLE WALL IN A VAULT ❑99 OTHER TANK MATERIAL-primary tank ❑ 1 BARE STEEL FIBERGLASS/PLASTIC ❑ 5. CONCRETE ❑95. UNKNOWN (Check one item only) ❑ 2. STAINLESS STEEL ❑4. STEEJL CLAD W/FIBERGLASS ❑ 8. FRP COMPATIBLE W/100%METHANOL ❑99. OTHER 3EINFORCED PLASTIC(FRP) TANK MATERIAL-secondary tank ❑ 1 BARE STEEL 3. FIBERGLASS/PLASTIC ❑ 8. FRP COMPATIBLE WI100%METHANOL ❑95. UNKNOWN (Check one item only) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD W/FIBERGLASS ❑ 9. FRP NON-CORRODIBLE JACKET ❑99. OTHER REINFORCED PLASTIC(FRP) [110 COATED STEEL ❑ 5. CONCRETE TANK INTERIOR LINING � GATE IN TALLED OR COATING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING �❑,,9�5. UNKNOWN433rp��//•• ' ❑ 2.ALKYD LINING ❑ 4. PHENOLIC LINING ❑ 6 UNLINED 13d'99. OTHERf/� r'�°'-L (F local use only) (Check one item on DATE INSTALLED OTHER CO�NFSAP ION ❑ 1. MANUFACTURED CATHODIC 3. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN 434 PROTECTIPLICABLE PROTECTION ❑ 4. IMPRESSED CURRENT ❑99. OTHER (For localuse Only) (Check one only) ❑ 2. SACRIFICIAL ANODE SPILL AND OVERFILL R INSTALLED TYPE lFor local use only) OVERFILL PROTECTION EDUIPM -ENT:YEAR INSTALLED (Check al/that apply) 1. SPILL CONTAINMENT W ❑ 1. ALARM 3. FILL TUBE SHUT OFF VALV rer2. DROP TUBE �� ❑ 2. BALL FLOAT ❑ 4. EXEMPT 3. STRIKER PLATE N.TANK LEAK DETECTION IF SINGLE WALL TANK Check all that 8PPW1 IF DOUBLLLEE,WALL TANK OR TANK WITH BLADDER Check one item onl ❑ 1, VISUAL(EXPOSED PORTION ONLY) ❑ S. MANUAL TANK GAUGING(MTG) 4ny -41SUAL(SINGLE WALL IN VAULT ONLY) ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ 6. VADOSE ZONE 2. CONTINUOUS INTERSTITIAL MONITORING ❑ 3. CONTINUOUSATG ❑ 7. GROUNDWATER ❑ 3. MANUAL MONITORING ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR) ❑ 8. TANK TESTING BIENNIAL TANK TESTING ❑99. OTHER V.TANK CLOSURE INFORMATION_/PERMANENT CLOSURE IN PLACE -T ESTIMATED DATE LAST USED(YR/MO/DAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 1 TANK FILLED WITH INERT MATERIAL? gallons ❑Yes ❑No v 113f0 1 CUPAFORM(4/99) ® ® Formerly SWRCB Form B