BILLING - Laserfiche WebLink

Home Browse Search

• • a ��o�o� � UNIFIED PROGRAM CONSOLIDATED FORM jpag.Ntta.7k)'��TANKS UNDERGROUND STORAGE TANKS- TANK PAGE 1 Page_of TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 4.AMENDED PERMIT ❑ S.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430. (Ca&am item only) ❑ 3.RENEWAL PERMIT .❑ 77.^PERMANENTLY CLOSED ON SITE (Specify meso) (Specify recon) p.Tn.TANK REMOVED KA WESS NAME(Sa wFA=YNg 0rDSA-DoiM8ainean.,) 1. FACILITY m: L N T0AQuuU eb LOCATION WITHIN SITE(optional) 431 W 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 I TANK ID# 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK Yes No 434, u�� Ir"res;'mmplde one page for Baca mn5anmmt. DATEINSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS (YEAR/MO) 437. k W)eAd 6 Xu 6 ADDITIONAL DESCRIPTION(Forbes me.Ny) {� 4311l;y}T/A9Ci�lL �" II.TANK CONTENTS TANK USE 439 PETROLEUM TYPE ❑ 1. MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (Ifehe<ked.crosrolne Petsolavn Type) ❑Ib. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION ❑ 2. NON-FUEL PETROLEUM ❑1c. MIDORADE UNLEADED ❑4. GASOHOL DA9.OTHER: G Tjx4 if) L- 0 3. CHEMICAL PRODUCT COMMON NAME (from Havrdoas Mae]s 1wemosy page) 441 CAS#(6om Navy .Nue I,lmereary psge) 442. 0 4. HAZARDOUS WASTE Uaalade4USNDIo ❑ 95.UNKNOWN III.TANK CONSTRUCTION TYPE OFTANK . INGLE WALL ❑3. SINGLE WALL WITH EXTERIOR ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. (Check a.item only) MEMBRANE LINER ❑95. UNKNOWN (:12. DOUBLE WALL 4. SINGLE WALL IN A VAULT ❑99. OTHER TANK MATERIAL-PsvnarY lavk BARE STEEL ❑3. FIBERGLASS/PLASTIC ❑5. CONCRETE ❑95 UNKNOWN 444. (Check one man only) [12. STAINLESS STEEL ❑4. STEEL CLAD W/FIBFRGLASS ❑8. FRP COMPATIBLE ❑99.OTHER: REINFORCED PLASTIC(FRP) W/100%METHANOL TANK MATERIAL-secondary tank 1. BARE STEEL 03. FIBERGLASS/PLASTIC 8. FRP COMPTIBLE W/100%METHANOL 95.UNKNOWN 445. (Check one dem only) ❑2. STAINLESS STEEL[14. STEEL CLAD W/FIBERGLASS [19. FRP NON-CORRODABLE JACKET ❑99.OTHER REINFORCED PLASTIC(FRP) [110. COATED STEEL 5. CONCRETE TANK INTERIOR LINING L RUBBER LINED ❑3.EPDXY LINING [15.GLASS LINING [195.UNKNOWN d46. DATE INSTALLED 447. OR COATING [12.ALKYD LINING ❑4.PHENOLIC LINING X.UNLINED [199.OTHER (Check one item only) OTHER CORROSION ❑1.MANUFACTURED CATHODIC [13.FIBERGLASS REINFORCED PLASTIC PRO* UNKNOWN 448. DATE INSTALLED 449. PROTECTION PROTECTION [14.IMPRESSED CURRENT ❑99.OTHER ITApplicable) ❑2.SACRIFICIAL ANODE SPILL AND OVERFILL YEARMSTALLED 450. TYPE 451. OVERFILL PROTECTION EQUIPMENT: YEARINSTALLED 452. (Check all that apply) ❑1.SPILL CONTAINMENT [11.ALARM ❑3.FILL TUBE SHUT OFF VALVE _ ❑2.DROP TUBE A,J/A [12.BALL FLOAT_ ❑4.EXEMPT / t /t ❑3.STRIKER PLATE �V A IV.TANK LEAK DETECTION (A description of the monitoring program shall be submitted to the local agency.) IF SINGLE WALL TANK 453. IF DOUBLE WALL TANK OR TANK WITH BLADDER 454, ( k all that apply) (Check one item only) I.VISUAL(EXPOSED PORTION ONLY) ❑5.MANUAL TANK GAUGING(MTG) ❑1.VISUAL(SINGLE WALL IN VAULT ONLY) 2.AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE ❑2.CONTINUOUS INTERSTITIAL MONITORING ❑3.CONTINUOUS ATG ❑7.GROUNDWATER [13.MANUAL MONITORING ❑4.STATISTICAL INVENTORY RECONCILIATION ❑8.TANK TESTING (SIR)+BIENNIAL TANK TESTING [:199.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? 452 PROW ❑Yes ❑ No UPCF hwfwrc-b(1/99)-1/4 httpV/"w.midoes.org Rev.02/16/00