COMPLIANCE INFO_2009-2014 - Laserfiche WebLink

Home Browse Search

o� ,*2'20/0� UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,II,111,IV,and IX below) 430 ® 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430a I DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID 0(Agency Use Only) 1 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 Lodi Memorial Hospital BUSINESS SITE ADDRESS 103 1 CITY 104 975#S Fairmount Ave. Lodi II.TANK DESCRIPTION TANK ID N UL 652095 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 Containment Solutions ®1.A STAND-ALONE TANK �' ❑2.ONE M A COMPARTMENTED UNIT.1937 C tete one page for each tom ment in the unit. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 03-18-2008 20,000 1 III.TANK USE AND CONTENTS TANK USE ❑ la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ® 5.EMERGENCY GENERATOR FUEL(HSC 425281.5(c)I ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 439a CONTENTS PETROLEUM: ❑ 1a.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 ® 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL. ❑ 11.OTHER NON-PETROLEUM(Specify): 440b IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL ® 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ 1.STEEL ®3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify) 445a OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED ®2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE ® 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 123 CCR§2636(al(3)1 458 PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ® 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ® 10.RIGID PLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 0 I.STEEL El 4.FIBERGLASS 0 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464e 464el VENT SECONDARY CONTAINMENT I.STEEL 4.FIBERGLASS IM 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464f 4641 VR PRIMARY CONTAINMENT I.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 0 90.NONE 99.OTHER(Specify) 4648 464SI VR SECONDARY CONTAINMENT C3 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 0 90.NONE E3 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL 2.IIIIACIA 0 2.DOUBLE WALL 0 90.NONE 464i, RISER PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC E3 90.NONE 99.OTHER(Specify) 4641 46St RISER SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED 19 1.SPILL BUCKET 0 3.STRIKER PLATEIBOTTOM PROTECTOR 0 4.CONTAINMENT SUMP 451a-c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ® 90.NONE 4692 CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS 0 to.RIGID PLASTIC 0-99.OTHER(S cif) 469b-c VIII. CORROSION PROTECTION =_ STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODES) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION: 1 certify that this UST system is compatible with the hazardous substance stored and that the information provided herein isdW,( accurate, and in full compliance with legal requirements. APPLICANT SIGNATURE 'n DATE 2/11/2009 ? 470 APPLICANT NAME(print) Dejdn Ristic 471 APPLICANT TITLE Project manager 472 UPCF UST-B-1/2 Rev.(12/2007)