COMPLIANCE INFO_2004-2009 - Laserfiche WebLink

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0\ arc. UNIFIEDPROGRAMCONSOLIDATEDFORM N` 1/ A G Ill�l( r TANKS UNDERGROUND STORAGE T[1/ANKS-TANK PAGE 1 '15 / (lKv pages per lank) Page of _ TYPE OF ACTION ❑1.NEW SITE PERMIT K 4.AMENDED PERMIT ❑ 5. CHANGE OF INFORMATION) ❑ 6. TEMPORARY SITE CLOSURE (Check one dem orlfy) ❑J.RENEWAL PERMIT 11 7. PERMANENTLY CLOSED ON SITE (Specify mason-forlocal use only) (Specify charge-for IoW use only) ❑ 8. TANK REMOVED 430 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) FACILITY ID CdV4o G A- r LOCATION WITHIN SITE(Oplionao 431 g�v ' 1.TANK DESCRIPTION i NK ID 9 TANK MANUFACTURER a//- )/]/1 1� t� COMPARTMENTALIZED TANK ❑ Yesq _R 051./4el, •''o v E a 9 WF_ (-b I t•( ('\ If'Yei,complete one page for each compartment. DATE INSTALLED(YEAR/MO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS /2t 000 f ADDITIONAL DESCRIPTION(Forlocal use only) II.TANK CONTENTS ��y(( TANK USE 432 PETROLEUM TYPE IAI'.1. MOTOR VEHICLE FUEL C1Ia. REGULAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL (ll marked,complete Petroleum Type) ❑10. PREMIUM UNLEADED 3. DIESEL ❑ 6.AVIATION FUEL ❑ 2. NON-FUEL PETROLEUM � ❑1c MIDGRADE UNLEADED ❑ 4. GASOHOL ❑99. OTHER C3 ]. CHEMICAL PRODUCT 'e ❑ 4. HAZARDOUS WASTE(Includes COMMON NAME(Imm Hazardous Materials Inyenlory page) CAS 0(from Hazardous Materials Inventory page) Used Oto 95 UNNOYM TYPE OF TANK ❑ 1. SINIII.TANK CONSTRUCTION SING WALL ❑ J. SINGLE WALL WITH ❑ S. SINGLE WALL WITH INTERNAL BUDDER SYSTEM (Check one dem ordy) �^�2. DOUBLE WALL EXTERIOR MEMBRANE LINER ❑95. UNKNOWN 114. SINGLE WALL IN A VAULT � ❑99. OTHER TANK MATERIAL-primary lank SSI(1 BARE STEEL ❑ J. FIBERGLASS I PLASTIC ❑ 5. CONCRETE 1195. UNKNOWN (Check one stem only) ❑ 2. STAINLESS STEEL ❑4. STEEL CLAD W/FIDERGLASS ❑ 6. FRP COMPATIBLE W/100%METHANOL ❑99. OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary tank ❑ 1 BARE STEEL ❑ 3. FIBERGLASS/PLASTIC ❑d 6. FRP COMPATIBLE W/100%METHANOL ❑95. UNKNOWN (Check one item only) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD W/FIBERGLASS yzsl 9. FRP NON-CORRODIBLE JACKET ❑99. OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL ❑ S. CONCRETE TANK INTERIOR LINING 1:1 1. RUBBER LINED ❑ J. EPDXY LINING ❑ 5. GLASS LINING ❑95. UNKNOWN433 DATE INSTALLED OR COATING �/ ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING 6. UNLINED El 99. OTHER (Check one item ) Ir51 (For local use only) PROTECTION IF APPLICABLE OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC G 3. FIBERGLASS REINFORCED PLASTIC El 95. UNKNOWN 434 DATE INSTALLED PROTECTION ❑ C IMPRESSED CURRENT 1199. OTHER (Check one Hem only) ❑ 2. SACRIFICIAL ANODE (For local use only) SPILL AND OVERFILL YEAR INSTALLED TYPE(For local use only) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED (Check aft that apply) 9 1 SPILL CONTAINMENT a 2_ ❑ 1.ALARM ICI 3. FILL TUBE SHUT OFF VALVE L ® 2. DROP TUDE Q�' ❑ 2. CALL FLOAT ❑ 4. EXEMPT ® 3. STRIKER PLATE 10 Z "4 TV.'TANKILEAK DETECTION IF SINGLE WALL TANK Check all that apply): IF DOUBLE WALL TANK OR TANK WITH BLADDER(Check one item only): ❑ 1, VISUAL(EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING(MTG) q❑q� 1. VISUAL(SINGLE WALL IN VAULT ONLY) ❑ 2, AUTOMATIC TANK GAUGING(ATG) I ❑ B.'VAUOSL ZONE Jt^I 2. (;U,41 UIJ 1IN000S IN I ER;;tI11AL MUNI I URUIG ❑ 3. CONTINUOUS ATG - ❑ 7. GROUNDWATER ❑ J. MANUAL MONITORING ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR)• ❑ S. TANK TESTING BIENNIAL TANK TESTING,e ❑99. OTHER V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YRIMOIDAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 4351 TANK FILLED WITH INERT MATERIAL? ganons ❑Yes ❑No CUPAFORM(4199) Formerly SVVRCB Form B