BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

low ' � o IFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 1 (two pages per tank) Pagc-1--of TYPE OF ACTION ❑1 NEW SITE PERMIT ® 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Check one item only) ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT (Specify mason-for local use only) (Specify reason-for local use only) ❑ 8 TANK REMOVED 430 BUSINESS NAME(Same as FACuffY NAME or DBA-Doing Business As) FACILITY ID: FLAG CITY CHEVRON 3 LOCATION WITHIN SITE(opumta!) 43j NEAR STREET FRONTAGE-6421 CAPITOL AVE., LODI, CA 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.) TANK ID# 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK ❑Yes rXI No 434 TANK q Q 5'f XERXES It"Yes",complete one page for each compartment. DATE INSTALLE (YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 43 04(est.)/1995 12,000 ONE ADDITIONAL DESCRIPTION(For local use only) 43t IL TANK CONTENTS TANK USE 439 PETROLEUM TYPE 44(1 ®1.MOTOR VEHICLE FUEL ❑1 a. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (If marked complete Petroleum Type) ®I b. PREMIUM UNLEADED ❑3.DIESEL ❑6.AVIATION FUEL ❑2. NON-FUEL PETROLEUM ❑1 c. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER ❑3. CHEMICAL PRODUCT COMMON NAME(from Hamrdous Materials Inventory page) 441 CAS#(from Hazardous Materials Inventorypage) 442 [14. HAZARDOUS WASTE (Incudes Used Oil) PREWSUP. GASOLINE (91) ❑95.UNKNOWN M. TANK CONSTRUCTION TYPE OF'LANK 0 1. SINGLE WALL 3. SINGLE WALL WITH 0 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one item only) EXTERIOR MEMBRANE LINER ❑95. UNKNOWN 29 2. DOUBLE WALL [14. SIGNLE WALL IN VAULT ❑99.OTHER TANK MATERIAL-primary rank 1. BARE STEEL 3. FIBERGLASS/PLASTIC 0 5.CONCRETE 0 95.UNKNOWN 441 (Check one item only) ❑2. STAINLESS STEEL [:14. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPTIBLE W/100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary tank C3 1. BARE STEEL 3.FIBERGLASS/PLASTIC 0 5. CONCRETE 73 95.UNKNOWN 445 (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD'W/FIBERGLASS ❑8. FRP COMPTIBLE W/100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10.COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING 0 1.RUBBER LINED D 3.EPDXY LINING LJ 5.GLASS_LNNG____0 95.UNKNOWN 446 DATE INSTALLED 447 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING ®6 UNLINED ❑99 OTHER (Check one item only) (For local use only) OTHER CORROSION ❑1 MANUFACTURED CATHODIC ®3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN 448 DATE INSTALLED 449 PROTECTION IF APPLICABLE PROTECTION ❑4 IMPRESSED CURRENT ❑99 OTHER (Check one item only) ❑2 SACRIFICIAL ANODE (For local use only) SPILL AND OVERFILL YEAR INSTALLED 450 TYPE poral use only) 451 OVERFILL PROTECTION EQUIPMENTNEAR INSTALLED 452 (check all that apply) ®I SPILL CONTAINMENT 2003 ❑1 ALARM E 3 FILL TUBE SHUT OFF VALVE ®2 DROP TUBE 2003 ❑2 BALL FLOAT ❑4 EXEMPT 2003 ®3 STRIKER PLATE 1995 IV.TANK LEAK DETECTION(A description of the monitoring progrun shall be submitted to the local agency.) IF SINGLE WALL TANK(check au that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 (Check one item aoly) ❑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 ®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 TANK FILLED WITH INERT MATERIAL? 457 n/a gallons El Yes ❑ No UPCF(12/99 revised) 10 Formerly SWRCB Form B