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Site#mer � Address� ® � <br /> AUGy � <br /> Date Contractor name/Tech name <br /> Petroleum Storage Tanks <br /> Tank# Product Capacity UST or AST AST Impact Barrier Split Striker Plate <br /> Tank Auxilary Manifoided/Siphoned <br /> R=Regular Unleaded Nominal Gallons What type of impact barrier is <br /> M=Mid Grade UST=underground l <br /> Order Nearest(p00) 9 present.(leave blank for USTQ TSP=Tank Striker Plate <br /> P=Premium Tank Split Tank <br /> per tank B=Bollards F= Bays DSP=DropT No Striker Plate AuxilaryTank Manifokied 1 Siphoned Tank <br /> monitor D=Diesel tricorn;torah for AST=Aboveground I=Inside Service Bays N=None <br /> W=Waste Oil Jenks iris than Tank L=Located away from traffic Yes or No Yes or No d so,to whet other tank) <br /> H=Heating Oil 500 gedons) N=AST present,no barrier UNK=Unknown (I <br /> 1 n <br /> Y N0 <br /> _T__ 1. <br /> 2 YE NO <br /> 3 ;2, a YES <br /> , <br /> 4 YES NO <br /> 5 YES NO <br /> 6 YES NO <br /> Petroleum Storage Tanks Vent Caps <br /> Tank# Material of Construction Corrosion Lined Tank Interstitial OR!WA/CA <br /> Protection S ce Remote Fiit Onl Manufacturer Model# <br /> DWF=Doubiewalf Fiberglass iMemagy Lined <br /> SWF=Singlewall Fiberglass Tank Does the <br /> DWS=Doubiewail Steel IC=Impressed Current B=Brine remote fill Does the UST Fill <br /> SWS=Singlewalf Steel SAC=Sac Anode t"°`='tl°'°1taipnRt D=Dry Remote Fill have a spill Riser have a OPW <br /> DWSP=Doublewak STiP °"M'°'°""""""` VC=Vawum bucket? tethered H=Husky Write Model Number <br /> NM=Non-metallic ,r„�,,,,,v,,,,,=t grounding cable? <br /> SWSP=Singlewafi STiP UNK=Unknown N- o a Yes or No M Morrison Bros in space provided <br /> CLD=Steel Clad wlFiberglass Yes or No UNK=Unknown YES or NO <br /> UNK=Unknown or NA Yes or No <br /> UNK=Unknown <br /> t 1� '4 <br /> 2 <br /> 3 <br /> 4 <br /> 5 <br /> 6 <br /> Product Piping Vapor Recovery System <br /> Tank# Material of Siphon Bar? Corrosion Stage II <br /> Construction Protection Stage I Type Pepe Pressure Mgmt System EVR System <br /> DWF=DW Fiberglass Does this tank dispense lhru <br /> SWF=SW Fiberglass the use of a Siphon Bar& BL=Balance <br /> Order SWS=SW Steel are the connections to each IC=Impressed Current CAS=Healy Clean Air <br /> SAC=Sac Anode 2PT=Two Point VA-Vacuum Assist Separator PT=PHIL.TITE <br /> per tank WRP=Wrapped tank v,"n.? CP=Coaxial Po et <br /> monitor Steel sv=Siphon,can.vlsMla NM=Non-metaNe PP ed VST=Vapor Systems Tech VR=VR Carbon Canister OPW=OpW VR <br /> UNK=Unknown CN=Coaxial Non-Poppeted HEVR=Healy w!EVR VST=VST Vapor Processor NA=No EVR <br /> FIX=Flexible SNV=Siphon,con.not visible NA=No Ste If <br /> UNK=Unknown NA=No Siphon 9e NA=Outside of California <br /> OF®Ij <br /> 2 e A, 0J• Vapor Pot Does the site have a vapor pol(drop out tank)?Yes or No <br /> 3 UST Monitoring System <br /> Printer Manufacturer Model Number Software Ver. <br /> 4 Does Monitor VR=Veeder Root <br /> have a Printer NA None Write Model Number in space provided Write Software Version <br /> Yes or No in space provided <br /> 5 <br /> 6 <br /> isauad011I4nota Page 1 of 4 <br />