COMPLIANCE INFO_2002-2008 - Laserfiche WebLink

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N UNIFIED PROGRAM (UP) FORM Q UNDERUROUND STORAGE TANKS - TAN PAGE 1 (two pages per tank) Page of ,9 TYPE OF ACTION [:]l.NEW SITE PERMIT [13.RENEWAL PERMIT ®5.CHANGE OF INFORMATION ❑TPERMANENTLY CLOSED SIT (Check one item only) ❑2.INTERIM PERMIT ❑4.AMENDED PERMIT ❑&TEMPORARY SITE CLOSURE ❑ 8.TANK REMOVED 4 BUSINESS NAME(Same as FACILITY NAME or DBA) FACILITY ID: 1 3JA � 0�0101310� 1(ojy UaalzCA s-�vi � Thc.. \o LOCATION WITHIN SITE(Optional) 1 I. TANK DESCRIPTION (A scaled plot plan with location(s)of UST system(s)including buildings and landmarks shall be submitted to the CUPA or PA.) Nd TANK ID# 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK 0 Yes ® No 434 MOCIP-^t W eldi vn Cc)- If"Yes",complete one page for each compartment. DATE INSTAL ED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 43s NUMBER OF COMPARTMENTS 437 C1 79 ZO,O®C7 I ADDITIONAL DESCRIPTION(For local use only) 438 II. TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 ®1. MOTOR VEHICLE FUEL ❑1a. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (If marked complete Petroleum Type) ❑1b. PREMIUM UNLEADED M 3. DIESEL ❑6. AVIATION FUEL [-12. NON-FUEL PETROLEUM ❑1c. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: ❑3. CHEMICAL PRODUCT COMMON NAME 441 CAS# 442 (from Hazardous Materials Inventory page) (from Hazardous Materials Inventory page) ❑4. HAZARDOUS WASTE(Includes Used Oil) ❑95.UNKNOWN III. TANK CONSTRUCTION TYPE OF TANK Ell. SINGLE WALL El 3. SINGLE WALL WITH ❑5. SINGLE WALL WITH INTERNAL BLADDER ((Check one item only) EXTERIOR MEMBRANE LINER ❑95. UNKNOWN 443 ®2. DOUBLE WALL ❑4. SIGNLE WALL IN VAULT ❑99. OTHER TANK MATERIAL-primary tank ' r 1. BARE STEEL 3. FIBERGLASS/PLASTIC ❑5. CONCRETE ❑95. UNKNOWN ((Check one item only) [32. STAINLESS STEEL 004. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPTIBLE W/100%METHANOL ❑99.OTHER 444 REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary tank 1. BARE STEEL 3. FIBERGLASS/PLASTIC ❑5. CONCRETE 95. UNKNOWN ((Check one item only) ❑2. STAINLESS STEEL ®4. STEEL CLAD W/FIBERGLASS [18. FRP COMPTIBLE W/100%METHANOL[]99.OTHER 445 REINFORCED PLASTIC(FRP) ❑10.COATED STEEL TANK INTERIOR LINING Ej 1.RUBBER LINED 3.EPDXY LINING [15.GLASS LINING 95.UNKNOWN DATE INSTALLED 447 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING ®6 UNLINED ❑99 OTHER 446 (For local use only) (Check one item only) OTHER CORROSION ❑1 MANUFACTURED CATHODIC ®3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN DATE INSTALLED 448 PROTECTION(IF APPLICABLE) PROTECTION ❑4 IMPRESSED CURRENT ❑99 OTHER 448 (For local use only) (Check one item only) ❑2 SACRIFICIAL ANODE SPILL AND OVERFILL (Check all that apply) YEAR INSTALLED 450 TYPE(local use only) 451 OVERFILL PROTECTION EQUIPMENT YEAR INSTALLED 452 ®1 SPILL CONTAINMENT ®1 ALARM ® 2 DROP TUBE ❑2 BALL FLOAT ❑ 3 STRIKER PLATE ❑3 FILL TUBE SHUT OFF VALVE ❑4 EXEMPT IV.TANK LEAK DETECTION(A description of the 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 454 (Check one item only) ❑1 VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MTG) ❑1 VISUAL(SINGLE WALL IN VAULT ONLY) ❑2 AUTOMATIC TANK GAUGING(ATG) ❑6 VADOSE ZONE M 2 CONTINUOUS INTERSTITIAL MONITORING ❑3 CONTINUOUS ATG ❑7 GROUNDWATER ❑3 MANUAL MONITORING ❑4 STATISTICAL INVENTORY RECONCILIATION ❑8 TANK TESTING (SIR) +BIENNIAL TANK TESTING ❑99 OTHER V.TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 455 ESTIMATED QUANTITY OF SUBSTANCEREMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 ESTIMATED DATE LAST USED(YR/MO/DAYF_�� ❑Yes ❑ No OFFICIAL USE ONLY DATE RECEIVED CUPA PA DISTRICT/INSPECTOR UP FORM(1/2000 Version) 1 UPF_LAC4:07_USTB THE CUPAs OF LOS ANGELES COUNTY