COMPLIANCE INFO_1985-2007 - Laserfiche WebLink

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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 1 (Two pages per tank) Page ` of TYPE OF ACTION ❑ I.NEW PERMIT ❑ 4.AMENDED PERMIT Rr5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430. (Check one item only) ❑ 3.RENEWAL PERMIT GAtt �s e� �Z ❑ 7.PERMANENTLY CLOSED ON SITE (Specify reason) (Specify reason) ❑ 8.TANK REMOVED BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3. FACILITY ID: I. �. td+ oa ® LOCATION WITHIN SITE(Optional) ` 431. IyT lllC "TION •. (--A:scaled plot plan wrtb.the location of the UST sysiem laclud` 'Wldin '"and landmarks shall be submitti6d to the loyal"a"envy). TANK ID# 432. TANK MA ACTURER 433. COMPARTMENTALIZED TANK Yes 610No 434. If"Yes,"complete one page for each compartment. DATE INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS 437 (YEAR/MO) ADDITIONAL DESCRIPTION(For local use only) 438. IIT0 UNTENT . TANK USE 439. PETROLEUM TYPE 440.E ❑ 1. MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED [32. LEADED [15. JET FUEL (If c ked,complete Petroleum Type) El lb. PREMIUM UNLEADED ;K. DIESEL ❑6. AVIATION GAS 72. NON-FUEL PETROLEUM ❑lc. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME (from Hazardous Materials Inventory page) `al' CAS#(from Hazardous Materials Inventory page) 442. ❑ 4. HAZARDOUS WASTE (Includes Used Oil) `L ❑ 95.UNKNOWN III,TANK CONSTRUCTION TYPE OF TANK D 1. SINGLE WALL 0 3. SINGLE WALL WITH EXTERIOR ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. (Check one item only) MEMBRANE LINER ❑95. UNKNOWN 2. DOUBLE WALL ❑4 SINGLE WALL IN A VAULT ❑99. OTHER TANK MATERIAL-primary tank 1. BARE STEEL JjM. FIBERGLASS/PLASTIC 5. CONCRETE 95.UNKNOWN 444. (Check one item only) ❑2. STAINLESS STEEL [34. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE [199.OTHER: REINFORCED PLASTIC FRP W/100%METHANOL TANK MATERIAL-secondary tank 1. BARE STEEL Ur. 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 3.EPDXY LINING 0 5.GLASS LINING 95.UNKNOWN 446. DATE INSTALLED 447. OR COATING ❑2.ALKYD LINING ❑4.PHENOLIC LINING [16.UNLINED ❑99.OTHER Check one item only) OTHER CORROSION 0 1.MANUFACTURED CATHODIC 934.FIBERGLASS REINFORCED PLASTIC 95.UNKNOWN 448. DATE INSTALLED 449. PROTECTION PROTECTION ❑4.IMPRESSED CURRENT ❑99.OTHER If Applicable) ❑2.SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED 450. TYPE 451, OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 452. (Check all that apply) 1.SPILL CONTAINMENT 2001 1.ALARM ❑3.FILL TUBE SHUT OFF VALVE_ 2.DROP TUBE 2.BALL FLOAT ❑4.EXEMPT 3.STRIKER PLATE I "TANEiK DETECTION (A Seri "oq of the Mo 4` ro.. shall be submitted Wjhe local a eti .)," 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) [12.AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE MI<CONTINUOUS INTERSTITIAL MONITORING ❑3.CONTINUOUS ATG ❑7.GROUNDWATER ❑3.MANUAL MONITORING ❑4.STATISTICAL INVENTORY RECONCILIATION ❑8.TANK TESTING (SIR)+BIENNIAL TANK TESTING ❑99.OTHER V.TANK CLOS tTE ISA ©N f''PERMANENT'CLOSC122E IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 455. ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456' TANK FILLED WITH INERT MATERIAL? 457' gallons ❑Yes ❑ No UPCF hwhvrc-b(1/99)-1/4 www.unidocs.org Rev.02/16/00