COMPLIANCE INFO_1999-2003 - Laserfiche WebLink

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UNIFIED PROGRAM CONSOLIDATED FORM ` �l(Q�bZ �. TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 1 (tan pages per tank) Page_of TYPE OF ACTION ❑I. NEW SITE PERMIT [14. AMENDED PERMIT ®5. CHANGE OF INFORMATION) C]6. TEMPORARY SITE CLOSURE (Check one item only) ❑7. PERMANENTLY CLOSED ON SITE ❑3. RENEWAL PERMIT []8. TANK REMOVED 430 (Specify reason-for local use only) (Specify change-for local use only) BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID# I I Circle K Stores, Inc. #2705447/05447 LOCATION WITHIN SITE(Optional) 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\vIp//��IFACTURER 433 COMPARTMENTALIZED TANK ❑ Yes No 434 0 $1406bq �l� �/ / ` If i tYes::,complete one page for each cc a ent111 j�{c�kA�J DATE INSTALL D(YE O) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 qqy a od ADDITIONAL DESCRIPTION(For local use only) 438 II.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 <1 -1' MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED El2. LEADED ❑ 5. JET FUEL ked,complete Petroleum Type) ❑I PREMIUM UNLEADED ❑ 3. DIESEL ❑ 6. AVIATION FUEL ❑ 2. NON-FUEL PETROLEUM Ic. MIDGRADE UNLEADED ❑ 4. GASOHOL ❑99. OTHER ❑3. CHEMICAL PRODUCT ❑ 4. HAZARDOUS WASTE(Includes COMMON NAME(Prom Hazardous Materials Inventory page) 441 CAS#(from Hazardous Materials Inventory page) 442 Used Oil) ❑95. XERXES III.TANK CONSTRUCTION TYPE OF TANK �,❑1. SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 71CI 2. DOUBLE WALL EXTERIOR MEMBRANE LINER ❑95. XERXES (Check one item only) -\ ❑ 4, SINGLE WALL IN A VAULT ❑99. OTHER TANK MATERIAL-primary tank ❑I. BARE STEEL R3- /PLASTIC ❑5. CONCRETE ❑95. XERXES 444 (Check one item only) ❑2. STAINLESS STEEL 4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE W/100%METHANOL 099. OTHER REINFORCED PLASTIC FRP TANK MATERIAL-secondary tank Ell. BARE STEEL3. FIBERGLASS/PLASTIC ❑8. FRP COMPATIBLE W/100%METHANOL 095. XERXES 445 (Check one item only) ❑2. STAINLESS STEEL ETZ STEEL CLAD W/FIBERGLASS ❑9. FRP NON-CORRODIBLE JACKET ❑99. OTHER REINFORCED PLASTIC(FRP) [:110. COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING ❑ L RUBBER LINED ❑3. EPDXY LINING ❑5. GLASS LINING ❑95. XERXES 446 DATE INSTALLED 447 OR COATING ❑2 ALKYD LINING ❑4. PHENOLIC LINING jk UNLINED ❑99. OTHER Check one item only) For local use only) OTHER CORROSION ❑1. MANUFACTURED FIBERGLASS REINFORCED PLASTIC ❑95. XERXES 448 DATE INSTALLED 449 PROTECTION IF APPLICABLE CATHODIC 4. IMPRESSED CURRENT ❑99. OTHER PROTECTION (Check one item only) ❑2 SACRIFICIAL ANODE (For local use only) SPILL AND OVERFILL YEAR INST ED 450 TYPE(For local use only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED j�I�,Oyf 452 (Check all that apply) SPILL CONTAINMENT r/� [11. ALARM ; 3. FILL TUBE SHUT OFF VALVE DROPTUBE ❑2. BALLFLOAT ❑4. EXEMPT Y-" STRIKER PLATE IV. TANK LEAK DETECTION (A description ojthe monitoring program shall be submitted to the local agency.) IF SINGLE WALL TANK(Check all that apply): 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER(Check one item only): 454 ❑I, VISUAL(EXPOSED PORTION ONLY) 05. MANUAL TANK GAUGING(MTG) Ell VISUAL(SINGLE WALL IN VAULT ONLY) 02. AUTOMATIC TANK GAUGING(ATG) ❑6. VADOSE ZONE 2. CONTINUOUS INTERSTITIAL MONITORING ❑3. CONTINUOUS ATG ❑7. GROUNDWATER 3. MANUAL MONITORING ❑4. STATISTICAL INVENTORY RECONCILIATION(SIR), ❑8. TANKTESTING 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 INERT MATERIAL? 457 gallons Yes .'�No UPCF(1/99 revised) Formerly SWRCB Form B