COMPLIANCE INFO_1998-2009 - Laserfiche WebLink

Home Browse Search

UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANKS -TANK PAGE 1 TANKS (two pages per tank) Page -1 of TYPE OF ACTION ❑ 1. NEW SITE PERMIT ❑ 4. AMENDED PERMIT ❑ 5. CHANGE OF INFORMATION) ❑ 6. TEMPORARY SITE CLOSURE (Check one item only) , e s _ \. (- _ rty ❑ 7. PERMANENTLY CLOSED ON SITE ❑ 3. RENEWAL PERMIT (Specify Mason -four local use only) (Specify change •for local use only) ❑ 8. TANK REMOVED 430 . \ BUSINESS NAME (Same as FACILITY NAME o(OBA - Doing Business As) FACILITY ID # - e ° 0 1 �0. k v 010 44 L•• v 0 rL LOCATION WITHIN SITE (Optloneo 431 i �,A 9 5 7, L LA 3`j oA. , I. TANK DESCRIPTION TANK 10 # TANK /� MANUFACTURER1 COMPARTMENTALIZED TANK Yes El No If *Yes', complete one page for each compartment. 111 S 6k O A ,� %1 `c.l✓r' DATE INSTALLED (YEAR/MO) TANK G /4 CAPACITY IN GALLONS NUMBER OF COMPART TS ADDITIONAL DESCRIPTION (Forlocal use only) 11. TANK CONTENTS TANK USE 432 PETROLEUM TYPE 1. MOTOR VEHICLE FUEL ❑ la. REGULAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL (1 marked, complete Petroleum Type) ❑ 1b. PREMIUM UNLEADED 3. DIESEL ❑ 6. AVIATION FUEL ❑ 2. NON -FUEL PETROLEUM ❑ 1c MIDGRADE UNLEADED ❑ 4. GASOHOL ❑ 99. OTHER ❑ 3. CHEMICAL PRODUCT COMMON NAME (from Hazardous Materials Inventory page) CAS # (from Hazardous Materials Inventory page) ❑ 4. HAZARDOUS WASTE (Includes Used oiq 95 UNKNOWN III. TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM (Check one item only) 92. DOUBLE WALL EXTERIOR MEMBRANE LINER ❑ 95. UNKNOWN ❑ 4. SINGLE WALL IN A VAULT ❑ 99 OTHER TANK MATERIAL - primary tank ❑ 1 BARE STEEL ❑ 3. FIBERGLASS / PLASTIC ❑ 5. CONCRETE 95. UNKNO t`}�p (Check one item only) 112. STAINLESS STEEL ❑ 4. STEEL CLAD W/FIBERGLASS C18. FRP COMPATIBLE W/100% METHANOL 1(99. OTHE LE;- `' REINFORCED PLASTIC (FRP) TANK MATERIAL - secondary tank ❑ 1 BARE STEEL ❑ 3. FIBERGLASS I PLASTIC ❑ 8. FRP COMPATIBLE W/100% METHANOL ❑ 95. UNKNOWN (Check one item only) ❑ 2. STAINLESS STEEL ❑ 4. STEEL C�' AD W/FIBERGLASS 9. FRP NON-CORROO113LE JACKET ❑ 99. OTHER REINFORCED PLASTIC (FRP) ❑ 10. COATED STEEL ❑ 5. CONCRETE ,y( TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING 1!195. UNKNOWN433 DATE INSTALLED OR COATING ❑ 2. ALKYD LINING El 4. PHENOLIC LINING [35 UNLINED El 99, OTHER (Check one item only) (For local use only) OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC Cl3. FIBERGLASS REINFORCED PLASTIC ❑ 95. UNKNOWN 434 DATE INSTALLED PROTECTION IF APPLICABLE PROTECTION ❑ 4. IMPRESSED CURRENT ❑ 99. OTHER (Check one item only) ❑ 2. SACRIFICIAL ANODE (For local use only) SPILL AND OVERFILL 1 ` l-1 YEAR INSTALLED TYPE (For local use only) OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED fL r (Check a# that apply! 1. SPILL CONTAINMENT %. 1. ALARM )!4 3. FILL TUBE SHUT OFF VALVE Iv 2. DROP TUBE %12. BALL FLOAT ❑ 4. EXEMPT ❑ 3. STRIKER PLATE `IV. TANK LEAK DETECTION IF SINGLE WALL TANK (Check all that apply): IF DOUBLE WALL TANK OR TANK WITH BLADDER Check one item on ): ❑ 1• VISUAL (EXPOSED PORTION ONLY) ❑ S. MANUAL TANK GAUGING (MTG) ❑ 1. VISUAL (SINGLE WALL IN VAULT ONLY) A2. AUTOMATIC TANK GAUGING (ATG) ❑ 6. VADOSE ZONE ❑ 2. CONTINUOUS INTERSTITIAL MONITORING ❑ 3. CONTINUOUS ATG ❑ 7. GROUNDWATER ❑ 3. MANUAL MONITORING ❑ 4. STATISTICAL INVENTORY RECONCILIATION (SIR) ❑ 8. TANK TESTING BIENNIAL TANK TESTING 1199. OTHER V. TANK CLOSURE INFORMATION / PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED ,NR)MOIOAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL? gallons ❑ Yes ❑ No CUPAFORM (4/99) 0 0 Formerly SWRCB Form B bk