Laserfiche WebLink
NIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 1 <br /> (fwo pages per tank) <br /> / Page _ D <br /> TYPE OF ACTION C1 1.NEW SITE PERMIT ❑ 4.AMENDED PERMIT <br /> (Check one item only) 5. CHANGE OF INFORMATION) ❑ 8. TEMPORARY SITE CLOSURE <br /> ❑ 7. PERMANENTLY CLOSED ON SITE <br /> ❑3.RENEWAL PERMIT <br /> (Specify reason-forlocal use only) (Speedy charge-for local use only) ❑ 8. TANK REMOVED 430 <br /> BUSINESS NAME(Same as FACILITY <br /> ILACILIITY NAME or DBA-Doing Business As) FACILITY ID# 1 <br /> L Ago <br /> LOCATION WITHIN SITE(Ophoneq 431 <br /> 1.TANK DESCRIPTION' <br /> TANK ID# / / -f F- - TANK MANUFACTURER <br /> COMPARTMENTALIZED TANK ❑ Yes ❑ No <br /> If'Yes',complete one page for each compartment. <br /> DATE INSTALLED(YEAR/MO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENT <br /> ADDITIONAL DESCRIPTION(Forlocal use only)- <br /> 11.TANK CONTENTS, <br /> ,�,// <br /> TANK USE 432 PETROLEUM TYPE <br /> LJ t. MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL <br /> (If marked,complete Petroleum Type) ❑lb. PREMIUM UNLEADED ❑ 3. DIESEL ❑ 6. AVIATION FUEL <br /> ❑ 2. :+JN-FUEL PETROLEUM ❑1c MIDGRADE UNLEADED ❑ 4. GASOHOL ❑99. OTHER <br /> ❑ 3. CHEMICAL PRODUCT <br /> ❑ 4. HAZARDOUS WASTE(Includes <br /> COMMON NAME(from Hazardous Materials Inventory page) CAS#(from Hazardous Materials Inventory page) <br /> _ <br /> Used Ail) <br /> 95, UNKNOWN <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK ,❑ 11 ANGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> (Check one item only) tip, DOUBLE WALL EXTERIOR MEMBRANE LINER ❑95. UNKNOWN <br /> ❑ 4. SINGLE WALL IN A VAULT ❑99 OTHER <br /> TANK MATERIAL-primary tank ❑ 1 BARE STEEL 3. FIBERGLASS/PLASTIC ❑ 5. CONCRETE ❑95. UNKNOWN <br /> (Check one Rem only) ❑ 2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑ 8. FRP COMPATIBLE W/100%METHANOL ❑99. OTHER <br /> ,RtINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-secondarytank ❑ 1 BARE STEEL 3. FIBERGLASS/PLASTIC ❑ 8. FRP COMPATIBLE W/100%METHANOL ❑95..UNKNOWN <br /> (Check one item only) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD W/FIBERGLASS ❑ 9. FRP NON-CORRODIBLE JACKET ❑99. OTHER <br /> REINFORCED PLASTIC(FRP) ❑10.COATED STEEL <br /> ❑ 5. CONCRETE <br /> TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING 5. GLASS LINING ❑95. UNKNOWN433 DATE INSTALLED <br /> OR COATING <br /> ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING ❑ 6. UNLINED 1199. OTHER <br /> (Check one Rem only) (For local use only) <br /> OTHER CORROSION DATEINSTALLED <br /> PROTECTION IF APPLICABLE ❑ 1. MANUFACTURED CATHODIC 3. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN 434 <br /> PROTECTION ❑ 4, IMPRESSED CURRENT ❑99. OTHER <br /> (Check one item only) ❑ 2. SACRIFICIAL ANODE (For local use only) <br /> SPILL AND OVERFILL YEAR INSTALLED TYPE(For local use only) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (Check all that apply) <br /> ❑ 1. SPILL CONTAINMENT ❑ 1. ALARM y13. FILL TUBE SHUT OFF VALVE <br /> ❑ 2. DROP TUBE ❑ 2. BALL FLOAT ❑ 4. EXEMPT <br /> ❑ 3. STRIKER PLATE <br /> IY.= ANK'Y EAKDETECTION <br /> IF SINGLE WALL TANK Check 90 that• IF DOUBLE WALL TANK OR TANK WITH BLADDER(Check one item only): <br /> ❑ 1, VISUAL(EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ 6. VADOSE ZONE ❑ 2. CONTINUOUS INTERSTITIAL MONITORING <br /> ❑ 3. CONTINUOUS ATG ❑ 7. GROUNDWATER ❑ 3. MANUAL MONITORING <br /> ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR)+ ❑ B. TANK TESTING <br /> BIENNIAL TANK TESTING ❑99. OTHER <br /> V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YRIMO/DAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 1 TANK FILLED WITH INERT MATERIAL? <br /> gallons ❑ ❑No Yes <br /> CUPAFORM(4/99) K� Formerly SWRCB Form B <br />