BILLING 2008 - 2015 - Laserfiche WebLink

Home Browse Search

01/04/2008 FRI 14: 06 FAX 20946 33 SJC EHD ®001/004 UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 (Two pages per lank) Page_of_ TYPr OF ACTION ❑ I.NEW PERMIT ❑ 4.AMENDED PF11MIT (K5.CIIANG L OF INFORMA'HON ❑ G.TL-MPORARY TANK CLOSURE 430. (C7x4cn u-Only) ❑ 3.RENEWAL ITAMIT -._----_ ❑ 7.PCRMANENI'LYmosul)ONsm" (S(ecify sounn) (S]>ttify rcasws) ❑ 8.'rANKRBMOVED BUSINESS NAME(Swca 1'ACILILY NAME orl)BA-Goiog INsiwu As) 3. 1 FACILITYID: 1, r 1-r, ' ' UL LOCATION WIT IN SITE(Oysional) 43) 3 Via. :.t>,LS:nJ t,o r,-< I.TANK DESCRIPTION (A scaled plot plats with the location of the UST system including buildings and landmarks shall be submitted to the Local a ency.) TANK 1D 14 ? 43= TANK MANUFACTURER 433. COMPARTMENTALIZED TANK LJ Yes ff No 434. 1%1C0 ^ OSI' �tl4�l3{� If"Yes."<onrykte o:¢page fa'arch conmannMni. DATE INSTALLG 435 TANK CAPACITY 114 GALLONS 436. NUMBER OF COMPAR'rM ENTS 447 (Y EAR/MO) A DD ITIONA L DESCR IPTION(lar 1-i,isconly) 438 2'ILn0 11.TANK CONTENTS TANK USE419 PEJ'ROLEUM TYPE 440. 21 L MO`1'Olt vEIHCLJ rltl L la. REGULAR UNLEADIiD ❑2. LEADED ❑5. JET FUFI. (tfchcckd,eanpine Pnminnn'Fpsc) C]16. PREMIUM UNLEAL)m C)3. DIE•SN. ❑G. AVIATION GAS ❑ 2. NON-Fl1EL PETROLEUM ❑le. MIUGRADE UNLEADED Q 4. GASOHOL. ❑99.ori-im: ❑ 3. CLiEM3CAL PRODUCT COMMON NAME(fcow HNv4eus Matenals hsvcwoiy page) 441. CAS#(floln 16ew4m Malcriats Invesnory page) 442. ❑ 4_ HA%ARDOUS WAS1T Qndudcx UsuJ O,p ❑ 95.UNKNOWN I11.TANK CONSTRUCTION lYI'L OFTANK ❑1. SINGLE WALL ❑3. SINGLE WALL Wrl'H EXTERIOR [15, SINGLE WALL WITH INTEKNAL BLADDER SYSTEM 443. (Clseckone i1cmonly) MT.-:MRANE LINER ❑95. UNKNOWN 2. DOUBLE WALL 4. SINGLL•WALL IN A 4'AULT Q 99. OT1im_. TANK MATERIA!,-p;ma y lank Q L BARE.ST'EIiL 3 F1R1r11G1rNSS I PLASTIC ❑5. CCNC:RETE ❑95.UNKNOWN 440. (Check one non only) ❑2. STAINLESS STErl. ❑4. STEEL CLAD WIFIB13RGL.ASS []8. FRI'COMPA II13LE ❑99.OTHUR: RI3INFORCEDPLAS"rIC FRP W/(00%M1:fHAN01, 1'.ANKMATGRIAL-sccondarylank C] 1. BARIiSMEL 3. F113FRGI.ASS/PLASTIC C]8. FItr.CON.inmu;wiioo°/ML--I'IIANOI. 095.UNKNOWN 445 (Clseck occ ilclnonly) ❑2, STAINLLSS STEEL. ❑4. S-,EELCLAD WiFIBL'RGLASS Q 9. FRI'NON-CORRODABLEJACKET ❑99.OTIdER HL•INl'ORCLIIl'LASTIC(FIV) ❑ In. COATFDS'I'L'EL S. CONCRETE. TANK IN'1-L'R1OR LINING C3 1,RUBBER LINL .E •'D ❑3PDXY LINING ❑5.GLASS LINING ❑95.UNKNOWN 446. DATE INS'FA L.I,IiD a47. OR COA TING ❑2.ALKYD LINING ❑4.11111?NOLIC LINING L,6.UNLINED ❑99.OTHER (Chcckonc i(cusoal ) O'1TIGR CORROSION ❑ I MA\mr-ACTURED CA'TILODIC .FtBL•1LGL.ASS 1lE1NCO1tCLD i'LAS'I'IC ❑95.UNKNOWN 446, DALE INSTALLED 449. PROTECTION 1'It0'R?C'(?ON ❑4.IMPRUSSED CURRENT ,;❑99.0711E"R _T__ (rA licabic) ❑2.SACRIFICIALANODF SPILL AND OVEKIYL,L YLw II ALL.M- 450. IYPL 451. �'.1tFILL 1'1tOTEC I'(ON EQUIPMGN'1': YEAR INSTALLED 452. (Check all that apply) Ki.SPILLCON'CALNMril. [+� _ L5 ALARM 03.rir.LTUBESIIUTOFFVALVE ❑2 DROPTURE __._. 2.HALL FI,OA'1' _,.. ❑4.FXEMI11- - J S1'RIKL'R I'LAI'E IV,TANK LEAK DETECTION (A de%c:riplion of the munitoria pro In shall be submitted to the local agency.) IF SINGLE WALL TANK 455. IF DOUBLE WALLTANIK OR TANK WITH BLADDER 454. (Check all that apply) (CLeck One ileal only) ❑ 1. VISUAI.(EXPOSED PORTI0NONLY) C15.MANUALI'ANKGAUGING(M'rG) QI.VISUAL(SINGLE WALLINVAULT ONLY) ❑2. AUT'OMA11C TANK GAUGING(ATO) ❑6 VADOSL ZONE (�(2.CONTINUOUS INTL•RS'11T1AL MONITORING ❑3. CONTINUOUS ATG ❑7 GROUNDWATER ❑3.MANUAL.MON[fOR1NG ❑4.S1ATES'I1CAL INVFNTOlkY RECONCHAA'1'ION ❑8.TANKTES'l(NG (SIR)s I3ILNNIAL TANKTESL'ING ❑99.O'rlilER V.TANK CLOSURE INFORMATION/ PERl41ANENT CLOSURE IN PLACE LSTIMATED DATE I-ASTUSED(YWMO/DAY) 455' ESIIMAIEDQUAN'I'ITYOFSUBS'LANCEREMAINING 1 157 grltom ❑Yes ❑ No UPCF Itwfwrc-b(1199)-114 wwwmaidocs,org Rev.02/14100 Z'd �OZZ-99t,-60Z ;gblM 8000`JMU� dee:ol 80 b0 Uef