BILLING_2001-2015 - Laserfiche WebLink

Home Browse Search

UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 (two pages per tank) Page of TYPE OF ACTION El NEW SITE PERMIT ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Check one item only) E] 7 PERMANENTLY CLOSED ON SITE IN 3 RENEWAL PERMIT (Spccifyreason-for local use only) (Speciryreason-for local use only) ❑ 8 TANK REMOVED 430 BUSINESS NAME(same as FACILITY NAME or DBr Doing Business As) FACILITY ID: l My Mini Mark 3 LOCATION WITHIN SITE(Optional) 431 Between Store and Pum S L 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 MANUFACTURER 433 COMPARTMENTALIZED TANK ®Yes ❑ No 434 91 SUL #1 Prepared Modern Building Company If"Yes",complete one page for each compartment. DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 1998 12,000 2 ADDITIONAL DESCRIPTION(For local use only) 436 II.TANK CONTENTS TANK USE 439 PETROLEUM TYPE, 440 �$]I. MOTOR VEHICLE FUEL [Ila. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (If marked complete Petroleum Type) M lb. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION FUEL ❑2. NON-FUEI.PETROLEUM ❑ I C. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER ❑3. CHEMICAL PRODUCT COMMON NAME (from llarardous Materials Inventory page) 441 CAS#(from Ilaiardouc Materials Invcnlory page) 442 ❑4. HAZARDOUS WASTE (Includes used.Oil) ❑95.UNKNOWN III. 'TANK CONSTRUCTION TYPE OF TANK I. SiNGLI?WALL 3. SINGLE WALL WTrTI 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one item only) EXTERIOR MEMBRANE LINER ❑95. UNKNOWN 2. DOUBLE WALL [14. SIGNLE WALL IN VAULT ❑99. OTHER TANK MATERIAL-primary tattle Lj 1. BAREST 3. FIBERGLASS/PLASTIC 5. CONCRETE 95. UNKNOWN 441 (Check one item only) ❑2. STAINLESS STEEL M 4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPTIBLE W/l00%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary tank LJ I. BARE STEEL 3. FIBERGLASS/PLASTIC El 5. CONCRETE 95, UNKNOWN 445 (Check one item only) ❑2. STAINLESS STEEL ®4. STEEL CLAD W/FIBERGLASS [18. FRP COMPTIBLE W/100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10.COATED STEEL El 5. CONCRETE TANK INTERIOR LINING ❑ I.RUBBER LINED ❑3.EPDXY LINING 5.GLASS LINING ❑45.UNKNOWN 446 DATE INSTALLED 447 OR COATING [:12 ALKYD LINING ❑4 PHENOLIC LINING ❑6 UNLINED ❑99 OTHER m (Check one iteonly) (For local use only) OTHER CORROSION ❑I MANUFACTURED CATHODIC 3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN 441 DATE INSTALLED 449 PROTECTION IF APPLICABLE PROTECTION ❑4 IMPRESSED CURRENT ❑99 OTHER (Check one item only) ❑2 SACRIFICIAL ANODE (Por local use only) SPILL AND OVERFILL YEAR INSTALLED 98 450 TYPE(local u.sc only) 451 OVERFILL PROTECTION EQUIPMENTNEAR INSTALLED 452 (Check all that apply) ❑I SPILL CONTAINMENT (9®2 DROP TUBE 1 ALARM El FILL TUBE SHUTOFF VALVE 2 BALL FLOAT ❑4 EXEMPT ®3 STRIKER PLATE IV.TANK LEAK)DETECTION(A description of the mmni(oring 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 ❑ EXPOSED PORTION ONLY (Check one item only) 1 VISUAL { } ❑5 MANUAL TANK GAUGING{MTG} ❑ I VISUAL(SINGLE WALL 1N VAULT ONLY) ❑2 AUTOMATIC TANK GAUGING(ATG) ❑6 VADOSE ZONE ❑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 IV.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 1 TANK FILLED WITH INERT MATERIAL? 457 gallons ❑Yes [] No UPCF(12/99 revised) 10 Formerly SWRCB Form B