COMPLIANCE INFO_2010-2011 - Laserfiche WebLink

Home Browse Search

UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this sectio and Sections I,II,III,IV,and IX below) 430 ❑ 1.NEW PERMIT [13.RENEWAL PERMIT (CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430a DATE EXISTING UST DISCOVERED: 4306 I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) 1 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 I:-CoNo G4S BUSINESS SITE ADDRESS 103 (ll, CITY L-cl loa H.TANKDESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANL CONFIGURATION:THIS TANK IS 434 ASTAND-ALONE TANK 71� OS-b S 3c ( x R r S ❑2.ONE IN A COMPARTMENTED UNIT. Comotete one page for each cmiyartinem in the umt DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 I 00-D III.TANK USE AND CONTENTS TANK USE Sr la.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ lc.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑4.HAZARDOUS WASTE(Indudes Used Oil) ❑'5,14MERGE GENERATOR FUEL[HSC§25281.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.'OTHER(Specify: 439a CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ la MIDGRADE UNLEADED qrIb.PREMIUM UNLEAD D 440 ❑ 3.DIESEL ❑ 5.JET FUEL 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL 13 11.OTHER NON-PETROLEUM(Specify): 4406 IV. TANKCONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL 2. OUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL .FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL ING ❑ 95.UNKNOWN [399.OTHER (S c' ): 444a SECONDARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify) 445a OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PROD! T/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ INGLE-WALLED LJ2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE 1.PRESSURE EW2.GRAVITY ❑3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(ax3)] 458 PRIMARY CONTAINMENT ❑ 1.STEEL F%,r4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL 924.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPINGITURBINE CONTAINMENT SUMP TYPE 1.SINGLE WALL ❑2.DOUBLE WALL ❑ 90.NONE 4644 VI.VENT,VAPOR RECO (VR)AND RISER/FILL.PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT LJ 1.STEEL 0 4.FIBERGLASS 11 10.RIGID PLASTIC 13 90.NONE El 99.OTHER(Specify) 464e VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGIDPLASTIC 9590.NONE ❑ 99.OTHER(Specify) 464f 464n VR PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS 0 10.RIGID PLASTIC ❑90.NONE ❑ 99.OTHER(Specify) 4648 464 1 VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 9,90,.NONE ❑ 99.OTHER(Specify) 464h 4Mhl VENT PIPING TRANSITION SUMP TYPE 1-SINGLE WALL ❑ 2.DOUBLE WALL NONE 4641. RISER PRIMARY CONTAINMENT 1.STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 464] RISER SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464k 4641 FILL COMPONENTS INSTALLED grel.SPILL BUCKET Gy3tSTRIKERPLATEIBOTTOMI PROTECTOR 0 4.CONTAINMENT SUMP 45la-c VII.UNDER DISPENSER CONTAINMENT.(UDC) CONSTRUCTION TYPE 1.SINGLEWALL ❑2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑99.OTHER(Specify) 469bc VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑4.IMPRESSED CURRENT ❑ 6.ISOLATION 448• UL APPLICANT'SIGNATURE CERTIFICATION:I certify that S system is compatible with the hazardous substance stored and that the information provided herein is true,accurate, and in full co witltleRal reauirements. APPLICANT SIGNATURE 1 DATE N, -71 t2 ,S, o 71 470. APPLICANT NAME(print_ 471. APPLICANT TITLE 472•