COMPLIANCE INFO_1986-2007 - Laserfiche WebLink

Home Browse Search

UNIFIED PROGRAM CONSOLIDATED FORM ltl TANKS I113/ ✓``� UNDERGROUND STORAGE TANKS - TANK PAGE I (Two pages per tank) Page _\_ of TYPE OF ACTION ❑ 1. NEW PERMIT ❑ 4. AMENDED PERMIT X5. CHANGE OF INFORMATION ❑ 6. TEMPORARY TANK CLOSURE 430. (C6eck one item only) ❑ 3. RENEWAL PERMIT ❑ 7. PERMANENTLY CLOSED ON SITE (Specify reason) (Specify teasoo) ❑ 8. TANK REMOVED BUSINESS NAME (Same as FACI=NAME or DBA - Doing Business As) 3.FACILITY ID: 1. U e - O b b D t LOCATION WITHIN SITE (optional) 431. - 5 ,3La L TANK DESCRIPTION (A scaled plot pian with the location of the UST system including buildings and landmarks shall be submitted to the local agency.) TANK .\ ID. /# 432. -(-A, D 14 2 OI OZ TANK MANUFACTURER 433. COMPARTMENTALIZED TANK [I Yes (� No 434. `�_' o , Qrt(✓-v l V'Yes,' complete one page for each compartment. DATE INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS 437. (YEAR/MO) C> C> Cy IV L` ADDITIONAL DESCRIPTION (Far tocalux only) 438- IL TANK CONTENTS TANK USE 439. PETROLEUM TYPE 440. ® 1. MOTOR VEHICLE FUEL ❑ 12L REGULAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL t (If necked, complete Petrokmn Type) ❑ lb. PREMIUM UNLEADED E 3. DIESEL [16. AVIATION GAS ❑ 2. NON -FUEL PETROLEUM ❑ ]c. MIDGRADE UNLEADED ❑ 4. GASOHOL ❑ 99.OTHER ❑ 3. CHEMICAL PRODUCT COMMON NAME (from Humdous Matmiats inventory page) 441. CAS# (from Hl dons a,r..mah inventory page) 442. ❑ 4. HAZARDOUS WASTE (Incudes Used oil) ❑ 95. UNKNOWN % t ' C III TANK CONSTRUCTION TYPE OF TANK 0 1. SINGLE WALL ❑ 3. SINGLE WALL WITH EXTERIOR ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. (Check one item only) MEMBRANE LINER ❑ 95. UNKNOWN DOUBLE WALL [14. SINGLE WALL IN A VAULT ❑ 99. OTHER TANK MATERIAL - primary tank Cl 1. BARE STEEL 3. FIBERGLASS / PLASTIC 5. CONCRETE ❑ 95- UNKNOWN 444. (Chcdkone item only) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD W/FIBERGLASS ❑ S. FRP COMPATIBLE ❑ 99. OTHER - REINFORCED PLASTIC 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 0 1. RUBBER LINED 0 3_ EPDXY LINING 5. GLASS LINING 95. UNKNOWN 446. DATE INSTALLED 447: OR COATING ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING (16. UNLINED ❑ 99. OTHER Check one item cal OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC [13. FIBERGLASS REINFORCED PLASTIC ❑ 95. UNKNOWN 448, DATE INSTALLED 449. PROTECTION PROTECTION ❑ 4. IMPRESSED CURRENT ❑ 99. OTHER (IfApplic.able)[12. SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED 450. (Check all that apply) 14 1. SPILL CONTAINMENT I L •C> TYPE 451, Di w OVERFILL PROTECTIONQ :PT YEAR INSTALLED 452. ® 1. ALARM i -L, 1. FILL TUBE SHUT OFF VALVE 1-6 O 2. DROP TUBE t 1 - t' t c 4 ,nr ❑ 2. BALL FLOAT 4. EXEM ® 3. STRIKER PLATE T" S - b y IV. TANK LEAK DETECTION (A description of the monitoring program shall be submitted to the local agency.) IF SINGLE WALL TANK 453. IF DOUBLE WALL TANK OR TANK WITH BLADDER a54. (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) ❑ 6. VADOSE ZONE 2. CONTINUOUS INTERSTITIAL MOMTORING ❑ 3. CONTINUOUS ATG ❑ 7. GROUNDWATER ❑ 3. MANUAL MONITORING ❑ 4. STATISTICAL INVENTORY RECONCILIATION ❑ 8. TANK TESTING (SIR) + BIENNIAL TANK TESTING ❑ 99. OTHER V. TANK CLOSURE INFORMATION / PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED (YR/MO/DAY) ass. ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456. TANK FILLED WITH INERT MATERIAL? 457. gallons ❑ Yes ❑ No 3