BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

ZKuAML AdftL o\ WH D PROGRAM CONSOLIDATED FO r� TANKS UNDERGROUND STORAGE TANKS- TANK PAGE (two pages per tank) Page 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 reason-for local use only) (Specify reason-for local use only) ❑ 8 TANK REMOVED 430 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) FACILITY IID: I IT USA GASOLINE#3696 3 F4,3dc7 LOCATION WITHIN SITE(optional) 431 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# nn 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK ❑Yes ® No 434 XV V OWENS CORNING If"Yes",complete one page for each compartment DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 1989 10,000 ADDITIONAL DESCRIPTION(For local use only) 438 IL TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 ®1. MOTOR VEHICLE FUEL [Ila. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL Qfmarkedcomplete Petroleum Type) ❑lb. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION FUEL [12.NON-FUEL PETROLEUM ®ic. MIDGRADE UNLEADED ❑4. GASOHOL [199.OTHER ❑3. CHEMICAL PRODUCT COMMON NAME (from Hazardous Materials Inventory page) 441 CAS#(from Hazardous Materials Inventory page) 442 ❑4. HAZARDOUS WASTE (Inchtdes Used Oil) ❑95.UNKNOWN III. TANK CONSTRUCTION TYPE OF TANK E3 I. SINGLE WALL 0 3. SINGLE WALL WITH 0 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 44 (Check one item only) EXTERIOR MEMBRANE LINER ❑95. UNKNOWN ®2. DOUBLE WALL ❑4. SIGNLE WALL IN VAULT [199. OTHER TANK MATERIAL-primary tank ®1. BARE STEEL 0 3. FIBERGLASS/PLASTIC 5. CONCRETE ❑95. UNKNOWN 444 (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPTIBLE W/100°4 METHANOL ❑99.OTHER REINFORCED PLASTIC(I") TANK MATERIAL-secondary tank ❑1. BARE STEEL ❑3. FIBERGLASS/PLASTIC 0 5. CONCRETE ❑95. UNKNOWN 445 (Check one item only) ❑2. STAINLESS STEEL IN 4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPTIBLE W/100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) [110.COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING 1.RUBBER LINED 3.EPDXY LINING 5.GLASS LINING 95.UNKNOWN 446 DATE INSTALLED 14 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 448 448 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(local use only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Check all that apply) ®1 SPILL CONTAINMENT 2003 ❑1 ALARM ❑3 FILL TUBE SHUT OFF VALVE ®2 DROP TUBE 2003 ®2 BALL FLOAT ❑4 EXEMPT ®3 STRIKER PLATE 1989 IV.TANK LEAK DETECTION(A descriptio[of the monitoring program shall be submitted to the local agency.) IF SINGLE WALL TANK(Check an that apply) 453 IF DOUBLE WALT,TANK OR TANK WITH BLADDER 151 (Check one item only) ❑I VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MIG) ❑1 VISUAL(SINGLE WALL IN VAULT ONLY) ❑2 AUTOMATIC TANK GAUGING(ATG) ❑6 VADOSE ZONE ®2 CONTINUOUS INTERSTITIAL MONITORING [:13 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 gallons ❑Yes ❑ No ❑16.ANNUAL INTEGRITY TEST(0.1 GPH) [116.ANNUAL INTEGRITY TEST(0.1 GPM ❑17. DAILY VISUAL CHECK ❑17. DAILY VISUAL CHECK VIIL DISPENSER CONTAINMENT DISPENSER CONTAINMENT ®1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE [14.DAILY VISUAL CHECK DATE INSTALLED 468 ❑2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5.TRENCH LINER/MONITORING 1989 ❑3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑6.NONE 469 DISPENSER+AUDIBLE AND VISUAL ALARMS IDL OWNER/OPERATOR SIGNATURE I certify that the information provided herein is true and accurate to the best of my knowledge. SIGN OF OWNE RATOR DATE 470 11/7/03 NAME OF OWNER/ PRATOR(print) I= OF OWNER/OPERATOR 472 DWARDS COMPLIANCE&TESTING OFFICER ,_SANDY Number(For local use only) 473 Permit Approved(For local use only) Permit Expiration Date(For local use only) 471