COMPLIANCE INFO_1991-2008 - Laserfiche WebLink

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J Adwkk UNIFIED PROGRAM CONSOLIDATED FORM �,2 v-,A TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 (Two pages per tank) Page_of TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 4.AMENDED PERMIT 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430. (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE (Specify reason) (Specify reason) ❑ 8.TANK REMOVED BUSINES NAME(Same as FACILITY NAME or DBA-Doin BmiinT As) 3. FACILITY ID: 1- LOCATION WITHIN SITE(Optional) 431. (A sc 6c3131ot, la> unth the ocatibh of the,U systemanclY�ling uilcirt gs ar�d#12radtlrarlcs shall be subinitted;,to.the„I 94 gencY.) TANK ID# � 432. -LANK MANUFACTU R 433. COMPARTMENTALIZED TANK LJ Yes No 434. ��- 02-S 1 i 1 0 2, -nnLOPn t nc) If"Yes,"complete one page for each compartment. DATE INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS (YEAR/MO) 437. ADDITIONAL DESCRIPTION(For local use only) 43& T K CONTENTS TANK USE 439. PETROLEUM TYPE 440. q&-JL MOTOR VEHICLE FUEL ❑1a. REGULAR UNLEADED ❑2. LEADED [15. JET FUEL (If checked,complete Petroleum Type) ❑lb. PREMIUM UNLEADED [13. DIESEL ❑6. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM 4EM. MIDGRADE UNLEADED [14. GASOHOL ❑99.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME (from Hazardous Materials Inventory page) 441' CAS#(from Hazardous Materials Inventory page) 442. ❑ 4. HAZARDOUS WASTE (Includes Used Oil) ❑ 95.UNKNOWN u a ANx' &STRueTION TYPE OF TANK ❑1. SINGLE WALL ❑3. SINGLE WALL WITH EXTERIOR [15. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. (Check one item only) MEMBRANE LINER ❑95. UNKNOWN DOUBLE WALL [14. SINGLE WALL IN A VAULT [199. OTHER_ TANK MATERIAL-primary tank ❑1. BARE STEEL W. FIBERGLASS/PLASTIC ❑5. CONCRETE ❑95.UNKNOWN 444. (Check one item only) ❑2. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE ❑99.OTHER: REINFORCED PLASTIC FRP W/100%METHANOL TANK MATERIAL-secondary tank ❑1. BARE STEEL 3. FIBERGLASS/PLASTIC ❑8. FRP COMPTIBLE W/100%METHANOL ❑95.UNKNOWN 445. (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑9. FRP NON-CORRODABLE JACKET ❑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 OTHER CORROSION ❑1.MANUFACTURED CATHODIC [13.FIBERGLASS REINFORCED PLASTIC ❑95.UNKNOWN 448. DATE INSTALLED 449. PROTECTION PROTECTION ❑4.IMPRESSED CURRENT ❑99.OTHER f Applicable) ❑2.SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED 450. TYPE 451. OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 452. (Check all that apply) [11.SPILL CONTAINMENT 1.ALARM ❑3.FILL TUBE SHUT OFF VALVE DROP TUBE 2.BALL FLOAT ❑4.EXEMPT STRIKER PLATE (A tlescriptr7(1 of t? iTiOitltorl�ig p)bgtam shall Ue stbmlttcd,to the=local agency♦) IF SINGLE WALL TANK 453. IF DOUBLE WALL TANK OR TANK WITH BLADDER 454. (Check all that apply) (Check one item only) ❑1. VISUAL(EXPOSED PORTION ONLY) ❑5.MANUAL TANK GAUGING(MTG) ❑1.VISUAL(SINGLE WALL IN VAULT ONLY) ❑2. AUTOMATIC TANK GAUGING(ATG) r ❑6.VADOSE ZONE ❑2.CONTINUOUS INTERSTITIAL MONITORING ❑3.CONTINUOUS ATG [17.GROUNDWATER ❑3.MANUAL MONITORING ❑4. STATISTICAL INVENTORY RECONCILIATION ❑8.TANK TESTING (SIR)+BIENNIAL TANK TESTING ❑99. OTHER V.TANK CLOSURE INFOItMATI0t4V PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST 1ISE (YR/MO/DAY) 455. ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456. TANK FILLED WITH INERT MATERIAL? 457. N gallons ❑Yes ❑ No UPCF hwfwrc-b(1/99)-1/4 http://www.unidocs.org Rev.02/16/00