COMPLIANCE INFO_1999-2007 - Laserfiche WebLink

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U ED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 1 � 9 (two page Page_of_ TYPE OF ACTION ❑1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE C)® � 7 2UU (I (Check one item only) ❑ 7 PERMANENT�L�Y�yC�LOSED O^N^ SITE ` u �`/A'J ❑ 3 RENEW AL PERMIT (Specify reason-for local use only) (Specify reason-for local use only) ❑ 8 TANK REMONE4'I R O N'YI E N TA L f^1 EAoLT I BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) FACILITY ID: IV C. LOCATION WITHIN SITE(optional 431 I.TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local agency.) 1 v� TANK ID# '1 432 T/A�NK JMANUFAC'T rURER 433 COMPARTMENTALIZED TANK ❑Yes No 434 T SvS702 Mod e4 yl We`SN- Gj Ty}- If"Yes".co complete mp page for each compartment. DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 19q i IZ, �s�r ADDITIONAL DESCRIPTION(For local use only) 438 II.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 Ix I. MOTOR VEHICLE FUEL ( la. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (If marked complete Petroleum Type) ❑lb. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION FUEL ❑2. NON-FUEL PETROLEUM ❑lc. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER [13. 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 III. TANK CONSTRUCTION TYPE OF TANK L3 I. SINGLE WALL 0 3. SINGLE WALL WITH 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one item only) EXTERIOR MEMBRANE LINER ❑95.UNKNOWN 192. DOUBLE WALL [:14. SIGNLE WALL IN VAULT ❑99. OTHER TANK MATERIAL-primary tank 1. BARE STEEL L1 3. FIBERGLASS/PLASTIC 5. CONCRETE L1 95. UNKNOWN 444 (Check one item only) ❑2. STAINLESS STEEL []4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPTIBLE W/100%METHANOL [199.OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary tank 0 1. BARE STEEL 0 3. FIBERGLASS/PLASTIC L1 5. CONCRETE 13 95. UNKNOWN 445 (Check one item only) ❑2. STAINLESS STEEL K4. STEEL CLAD W/FIBERGLASs ❑8. FRP COMPTIBLE W/100%METHANOL [199.OTHER REINFORCED PLASTIC(FRP) ❑10.COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING D 1.RUBBER LINED 0 3.EPDXY LINING LJ 5.GLASS LINING 95.UNKNOWN 446 DATE INSTALLED 447 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING ❑6 UNLINED (Check one item only) ❑99 OTHER (For local use only) OTHER CORROSION ❑1 MANUFACTURED CATHODIC ❑3 FIBERGLASS REINFORCED PLASTIC [:195 UNKNOWN 448 DATE INSTALLED 449 PROTECTION IF APPLICABLE PROTECTION ❑4 IMPRESSED CURRENT ❑99 OTHER (Check one item only) ❑2 SACRIFICIAL ANODE (For local use only) SPILL AND OVERFILL YEAR INSTALLED Tj 450 TYPE(local use only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED q y 452 (Check all that apply) %I SPILL CONTAINMENT ®2 DROP TUBE ❑1 ALARM �3 FILL TUBE SHUT OFF VALVE ❑2 BALL FLOAT ❑4 EXEMPT 3 STRIKER PLATE IV.TANK LEAK DETECTION(A description of the monitoring program shall be submitted to the local agency.) IF SINGLE WALL TANK(Check all that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 (Check one item only) ❑I VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MTG) 1:11 VISUAL(SINGLE WALL IN VAULT ONLY) ❑2 AUTOMATIC TANK GAUGING(ATG) ❑6 VADOSE ZONE 0 2 CONTINUOUS INTERSTITIAL MONITORING Q 3 CONTINUOUS ATG ❑7 GROUNDWATER ❑3 MANUAL MONITORING ❑4 STATISTICAL INVENTORY RECONCILIATION ❑8 TANK TESTING (SIR) BIENNIAL TANK TESTING ❑99 OTHER IV.TANK CLOSURE INFORMATION!PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAININGANK FILLED WITH INERT MATERIAL? 457 456 T gallons ❑Yes ❑ No UPCF(12/99 revised) 10 Formerly SWRCB Form B