COMPLIANCE INFO_1986-2006 - Laserfiche WebLink

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v UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 1 (two pages per tank) Page of TYPE OF ACTION ❑ I 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 (Speciyreason-for local use only) (Specify reason-for local meonly) ❑ 8 TANKREMOVED 430 BUST ESSNAME(Samccas�FrAC1uT{}NAM o DBA-Doing Business As) FACILITY ID: l { C) ' t - 3 LOCATION WITHIN SITE(Optional) 431 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 No 434 rIf"Yes",complete one page for each compartment. DATE INSTALL D(YEAR/MO) a35 TANK CAPACITY IN GALLONS 43G NUMBER OF COMPARTMENTS 437 DD ADDITIONAL DESCRIPTION(For local use only) 438 Il.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 1. MOTOR VEHICLE FUEL ❑ la. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (If marked complete Petroleum Type) ❑ Ib. PREMIUM UNLEADED3. DIESEL 06. AVIATION FUEL [32. NON-FUEL PETROLEUM Eli.. MIDGRADE UNLEADED ❑4. GASOHOL [199.OTHER ❑3. CHEMICAL PRODUCT COMMON NAME (from Hazardous Materials Inventory page) 441 CAS#(from Hazardous Materials Inventory page 1 442 ❑4. HAZARDOUS WASTE (Includes Used Oil) 1 ❑95.UNKNOWN 1 Ili. TANK CONSTRUCTION TYPE OF TANK 01. SINGLE WALL 3. SINGLE WALL WITH ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one item only) EXTERIOR MEMBRANE LINER ❑95. UNKNOWN 2. DOUBLE WALL ❑4. SIGNLE WALL IN VAULT ❑99. OTHER TANK MATERIAL-primary tank I. BARE STEEL El 3. FIBERGLASS/PLASTIC 5. CONCRETE 0 95. UNKNOWN 444 (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPTIBLE W/100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary tank 0 1. BARE STEEL . FIBERGLASS/PLASTIC C1 5. CONCRETE ❑95. UNKNOWN 445 (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS C18. FRP COMPTIBLE W/100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10.COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING ❑1.RUBBER LINED ❑3.EPDXY LINING ❑5.GLASS LINING 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 E] !MANUFACTURED CATHODIC El3 FIBERGLASS REINFORCED PLASTIC 95 UNKNOWN 448 DATE INSTALLED 449 PROTECTION IF APPLICABLE PROTECTION ❑4IMPRESSED 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) �ISPILL CONTAINMENT ®� ALARM 3 FILL TUBE SHUT OFF VALVE 2 DROP TUBE ❑2 BALL FLOAT ❑4 EXEMPT ❑3 STRIKER PLATE IV.TANK LEAK DETECTION(A description of the monitoring 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 (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 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 H INERT MATERIAL? 457 ESTIMATED DATE LAST USED(YR/MO/DAY) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WIT gallons ❑Yes El No UPCF(12/99 revised) 10 Formerly SWRCB Form B I