ML18152A474

Forwards Completed Registration Form for Renewal of ASTs at Surry Nuclear Power Station,Iaw Section 9VAC 25-91-100.F

ML18152A474
Person / Time
Site:	Surry
Issue date:	05/19/1999
From:	Sprouse W VIRGINIA POWER (VIRGINIA ELECTRIC & POWER CO.)
To:	Harshman A VIRGINIA, COMMONWEALTH OF
References
NUDOCS 9906150226
Download: ML18152A474 (14)

Text

Certified Mail Return Receipt Re.quested

• lnnshrook *rl*1_ /init. u"/ c*('j,'/c;*

'i(H)(J [)omi11iu11 8u11h'l',ir'I c;tc11 .llle11. \ 'ir,~i11ir1 ..?30(iu May lQ, 1999 AST Registration Program Attention: Amy Harshman Virginia Department of Environmental Quality VJRGJflJIA POWER 629 East Main Street Richmond, VA 23240-0009 Re: AST REGISTRATION -SURRY NUCLEAR POWER STATION (ODCP NO.

FC-04-3535)

Dear Ms. Harshman:

In accordance with section 9VAC 25-91-100.F of the Facility and Aboveground Storage Tank (AST) Regulations, Virginia Power is renewing the registration for the ASTs at the Surry Nuclear Power Station. Attached is the completed registration renewal form. There were no changes to the previously submitted registration forms; however, as we were not able to determine if AST No. OBFOTKl was previously registered, we have included a copy of the registration form and registration fee for that tank. The attached check for $75.00 includes $50.00 for the renewal and $25.00 for the registration of AST No. OBFOTKl.

Please contact me at 273-3552 with any questions .

. Sprous , Jr., PE Senior Engineer Environmental Policy & Compliance Attachments cc:

U.S. Nuclear Regulatory Commission Region II Atlanta Federal Center 61 Forsyth Street, SW Suite 23T85 Atlanta, GA. 30303 RE: Surry Units 1 and 2 Docket Nos. 50-280/50-281 License Nos. DPR-32/DPR-37 9906150226 990519 PDR ADOCK 05000280 p PDR

~Mn.:*

If .1 Amy Harshman May 19, 1999

• l !

Page 2

(, . U.S. Nuclear Regulatory Commission Attn: Ducument Control Desk Washington, DC 20555 RE: Surry Units 1 and 2 Docket Nos. 50-280/50-281 License Nos. DPR-32/DPR-37 Mr. R. A. Musser NRC Senior Resident fuspector Surry Power Station

.,'\,.

/. DEQ Form 7.541-AST

• GP.-iIA DE? ..>,.RTI.!EXT OF EN'.1RONME~TAL OU REGISTRATION RENE\VAL FOR ABOVEGROUI'11) STOR.\.GE TANK (AST) FACILITY I State use only: FAC. ID. ID - L--1., . ._I_..__I~...__._I-.J] .*

L OWNERSHIP OF FACILITY:

Owner Name: (First. Middle, Last):

-I V I I R I~ I IN IT A I? Io IWI EI RI I I

Street Address:

I I 1- I I I I I? IO I IB *I O l'x I Iz Ito Ito I fa It, I I I , .I I**I Citv:

I I* .

jr;jijc_jHjMjajtJIDI I I I I I I I I I I I Countv:

I State:

r I I I I Zip Code (+4) .

I . I I I I I . I I I I I I I I I I I *I I -

-1 *

(Area code) Phone number: * * *

!V!AI !2-! 3 lzltol1 j+ I I I I l~lolt-Jj -j ,j7 j/ l3lololal Il. OPERATOR OF FACillTY:

Operator Name: (First, Middle, Last):

I VII I R. j 6 I IN 'b: IA I I? I IW I& If< I I I .

Street Address: .

C O I I I I Pj O I IIS Ic I)( I IZ I to , .to I I~ I I I I I Citv: .

cf, I I I J I I.

III. CONTACT PERSON FOR FACILITY:

Contact Name: (First, Middle, Last): *

!sl,!AITITlolNl !Ml~INIAl~l6"1RI I I I I l**j I I I

. Street Address:.

• I5 !5 I7 I I IH I 16 I I:r: I<<s I IA IJJ ID I I9R I I I I I I I ]

O O O A h r~

J_

ILl IR If<-1 'i I I I I I I I I I I I I I I I I I I I ]

Countv:

• 1, 1v. J..UCAIION OFFACILfIY:

La.tiri.tde: Lomritude:

'~

r I Facilitv Name or Co1lV Site Identifier:

I~ I I I Street Address: I IJ Citv:

I :J I I I I State: Zip Code (+4) (Area code)

I I Phone number:

~ I 2 Is 181 ~ 131 ~ I 0 131 Ii] I 71 ~ I iJ I :sl0 ls,....__I_.__----......__.I*

V. TOTAL NUMBER OF REGISTERED ASTs AT FACILITY: B.l-l1l<tl VL TOTAL AST STORAGE CAPACITY OF FACILITY: (In g~ons) *1 I VJJ. OIL DISCHARGE CONTINGENCY PLAN NUMBER:

(Applies only to AST Facilities 25,000 gallons or greater.) I Fl c.. j - I o IL.f I -I 31 s j 3 j 5 I VIII. RENEWAL FEE: (Required every 5 years from date ofregistration.)

- RENEWAL FEE IS ENCLOSED: 1. Yes ~ 2. No O . (Make check payable to Treasurer of Virginia.)

~ a i Rt:ncwal forms will not be accepted by the board as complete wucss the applicable fee ba.s been paid. No fee is required for a "notification" or an AST replacement (Le. relocation or reposftlonin: or an e:mtln: ASI), upv,ide, repair, or closure.

. . Registration Renewal fees are as follows:

• a. .An Individual AST (new, existing. replaced or brought back e. Two facilities with one AST at the first fa.cility and two or more at the other- S 75;

.

• into use after permanent closure)

• S2S; f. Two or more facilities with two or more ASTs each ~ SI 00;

b. One facility with one AST* S2S; g. Tbrec facilities with one AST each .. S75; or

c. One fa.cility with two or more ASTs

• SSC; h. Tbrec fa.cilities with two or more ASTs at the first facility and one: AST. a.t =h other

d. Two facilities with one AST at each facility .. SSO; facility* SIOO.

• IX. ALL OTIIER INFORi"\!ATION ON THE PREVIOUSLY SUBl\llTIED REGISTRATION FORM ( 75-10-ASl) REI'r!AINS CORRECT: 1. Yes ~ 2. No 0

x. IF ANY OTHER INFORMATION ONTIIE PREVIOUSLY SUBi\mTED REGISTRATION FORM (75-IO-AS1) HAS CHANGED, AN AMENDED REGISTRATION FORM (7540-AS1) MUST BE ~NCLO~ED.

XI. OWNER CERTIFICATION: (Read and sign after completing all sections of this registration renewal)

"I certify under penalty oflaw that this document and all attachments were prepared under my direction or .supervision in accordance with a system designed to ensure that qualified personnel properly gathered and evaluated the infonnation submitted.

Ba.red on my inquiry ofthe person or persons who manage the system, or those persons directly responsible for gathering the information, the information.submitted is, to the be.rt ofmy knowledge and belief, true, c1,1rs1B-, and~ete. I am aware that there are significant penalties for submitting false information, including the possib

• ity offines and impris~ntfor knowing violations. "

• Signature _ __:_.==::::::_:_:::::::5~S:,......,,._ _ _ _ _ _ _ _ _~ - - - -

-1cxicic-Jc'lc'lc'lcic-Jc Mail form and fee to:

Department of Environmental Quality; Office of Financial Management P.O. Box 10150; Richmond, VA 23240

,7.1242

• VIRGINIA DEPARTMENT OF ENVIRONMENTAL QUALITY FACILliY AND ABOVEGROUND STORAGE TANK REGISTRATION HOW TO FILL OUT THE FORM We use an optical scanner to quickly and accurately read the large v*olume of registration forms that we receive. To ensure that we can process youi:: form quickly, please PRINT your characters in BLACK ink on the registration form so they look like the block characters in the samples below (Take special note of the letters "O" and "Q"). PLEASE KEEP THE CHARACTERS INSIDE THEIR RESPECTIVE BLOCKS. Any errors can be corrected with white correction fluid. Thank you for your cpoperation.

EXAMPLE OF HANDWRITING FOR: TEXT Aisle Die.IF IGI\-\IIIJ '!'jLIM NiolP QjRjSITlulvlw ~l'<IZ EXAMPLE OF HANDWRITING FOR: NUMERIC CHARACTERS EXAMPLE OF SHADING FOR: SELECTIONS Shade circles like this:

• Not like this: ~ ~

REGISTRATION FEES:

Check or money order should be attached to this page only.

Attach check or money order in this area.

(staple to this page only)

Do not stapie to reg~stration form.

II I Ple*se do not staple or fold registration sheets.

11* . [5]J 2-~258 VIRGINIA DEPARTMENT OF ENVIRONMEN"f!L QUALITY

• p;o. Box 11143, Richmond VA 23230-1143 DEQ Form 7540-AST: REGISTRATION FOR ABOVEGROUND STORAGE T ANK(S) Page: 1 II ST~TEUS~,DateReceived IIIIIII FAC.ID D I I I I I I I II GENERAL INFORMATION INITIAL REOl'STRATION: An owner of an aboveground storage tank (AS"l') facility or an owner of an individual AST shall register all ASTs located within the Commonwealth with the Dcpartn:ient of Environmental Quality and the local director or coordinator of emergency aervicc:s within 90 days of the effective date of VR 680-14-12. The primary purpose of this registration i1 to identify and inventory the aboveground storage tanks containing oil located in the Conunonwealth of Virginia.

WHO t.:{UST NOTIFY? Virginia Code § 62.1-44.34: 19. I requires that the operator of a facility locaied wilhin the Commonwealth with an aboveground storage capa~ ity of more than 1,320 gallons of oil or with im individual aboveground storage tank capacity of more than 660 gallons of oil register their facilities. Operaton must also provide an inventory of aboveground storage tanks at the facility. An operator means any person who owns, operates, charters (by demise), rcnll or otherwise exercises control over or responsibility for a facility or a vehicle or a vesael.

WHAT IS AN ASf? Abovearound storage tank(s) or

• AST" means any one or combination of tanks, including pipes, used to contain an accumulation of oil at atmospheric prcuure, and the volume of which, including the volume of the pipes, ia more than ninety percent above the surface of the ground. Thi* term includes any tank or device used to contain an accumulation of oil and constructed of non-earthen materials, such as concrete, steel, or plastic that provides structural suppon.

This tenn docs not include (i) line pipe and breakout tanks of an intcntate pipeline regulated under the Hazardous Liquid Pipeline Safety Act of 1979, or (ii) flow-through proceu equipment used in the proceuing or treatment of oil by physical, biological, or chemical means.

• WHAT ASTs ARE EXEMPT FROM THE REGISTRATION REQUIREMENTS? The requircmeni. oflhis regulation do NOT .apply to:

l. operaton of tank vessels or vehicles;

2. an operator of: a. an AST containi111 petroleum, includir!i crude oil or any fra~tion !hereof, that is subject to and specifically listed or desi,nated *as a hazardous substance under subparagraph* (A) through (F) of Section 101(14) oflhe Comprehensive Environmental RespollllC, Compensation, and Liability Act (CERCLA)

(42 U .S.C. § 9601); b. any wastewater treatment tank system that is part of **wastewater treatment facility regulated under§ 402 or § 307(b) of lhe Clean Water Act.; c. an AST regulated by the Department of Mines, Minerala, and Energy under Chapter 22.1 of Title 45.l oflhe Code of Virginia; d. an AST used for the*

storage ofproduci. lhat arc regulated punuanl to lhe Federal Food, Drug, and Cosmetic Act (21 U.S.C. § 301, et seq.); e. an AST used to store hazardous w1S1e listed or identified under subtitle C of the Solid Waste Disposal Act, (42 U.S.C. § 6901, et seq.) or a mixture of such hazardous w111e1 and olher regulated substances;

f. an AST with a storage capacity of 660 gallons or leu lhat i1 used for storing heating oil for consumption on the premises where stored; g. an ASf used to store propane gas; h. an AST of 660 gallons or leu located at a fann or residence that i1 used-for storing motor fuel for noncommercial purposes or for storin1 substances that

• arc used to facilitate lhe production of crops, livestock, and livestock products on*a farm; i. an AST used to st.on: nonpetroleum hydrocarbon baaed animal and vegetable oils; j. a nonstationary AST liquid trap or associated 1alherirJi lines directly related to oil and 1as production or 1atherirJi; k. a drum, barrel, or portable AST lhat has a storaae capacity of lesa than 110 1allons; I. a surface impound meal, pit, pond, or laaoon; m. a storm-water or wastewater collection system; or, n. equipment or machinery that contains oil for operational purposes.

WHAT on.s ARE COVERED? "Oil" means oil ofany kind in any fonn, includirJi but not limited to, petroleum and petroleum by-products, fuel oil, lubricating oils, sludge, oil refuae, oil mixed wilh other wastes, crude oils, and all other liquid hydrocarbons rcg1rdle11 of specific gravity.

WHEN TO REGISTER? A. An operator of a facility or an operator of an individual AST shall register all AST* located wilhin lhe Conunonweallh wilh lhe Department of Environmental Quality and lhe local director or coordinator of emer,ency services within 90 days of the effective date of the regulation. For any registration or notification submitted pursuant to§ S ofVR 680-14-12, an operator shall submit this fonn to the Depanmenl of Environmental Quality. B. 1n addition to the initial registration required by§ 5 A ofVR 680-14-12, an operator shall register a new or converted facility or AST wilh lhe department and local din:ctor of emergency services wilhin 30 days after being brought into use. An operator of a facility or AST shall notify the department using lhis fonn within 30 days after any AST upgrade. repair, replacement, temporary closure, and permanent closure.

• INSTRUCTIONS

{hmm, please PRINT (BLACK INK) all items except "signature" in sections XIII and XIV. This form must be completed for each facility containing aboveground storage tanks. Photocopy p&ges S through 9 for each tank. Complete tank information pages for each aboveground storage tank greater than or equal to 110 gallons (un~ exempted) if located in a facility with an aggregate capacity greater than 1,320 gallons or if an individual abo*eground stonge tank is greater than 660 gallons.

~ -OWNERSHIP OF T ANK(S):

Owner Name:

(First,Middle,Lastl o lw Ic: 1~ I I I I I I I I I I II

~ 1~ 1~ I I* I I I I I I I I I l I Street Address:

City:

County:

I I I I I I I I I 1* I I I Ii I I I I I I I I I I I I I I I I I I I I I I II State: ZIP Code(+ 41: Phone Number: (Include area coda)

II

- II .[fil 29258 DEQ Form 7S40-AST: REGISTRATION FOR ABOVEGROUND STORAGE TANK(S)

II. OPERATOR OF T ANK(S):

• Page: 2 II

~r:::~i~~l:~:~t) IV 1*l R G, I, IN I I~ I Ip IO IW Ic I~ I I I I I I I I I I ! J*

I Street Addre&1: IPI O I P., lo ,~ I I*2. I~ I~ ICo ,~ I I I I I I I I I I I i i

• City: IR II c_ k IMI 0

• I~ lo I I. I I I l I I I I I I \ I I \ \ \

County: I I I* I I I I I I I I I I I I I I I I I I I I. !

State: ZIP Code(+ 4): ~hone Number: (Include area code) ill. CONTACT PERSON IN CHARGE OFTANK(S):

• Street Addreas:

City:

I.

County:

State: ZIP Code I+ 4) : Phone Number: (Include area cod!ll

[Q I ~ I ) I ~ I YI ~ I - I I I I II ~ I O I I l ~ I b Is- I -I-1-.I_ l)-1°--.-1---,I 1 ~I IV. LOCATION OF TANK(S): Latitude (Example: 0423612N ) Longitude (Example: 08S24l7W )

Facility Name or I I I I I I *I I* I . I I I I I I I I l .

Street Addresa:

City:

County:

State: ZIP Code I+ 4) : Phone Number: (Include area code)

~ I ~, JI *rl zI~ I-I I I I 11 )> IO I11131 (o Is-1--1~\1---.--o Ic--,----,luI II a

II~ 29258 DEQ Form 7540-ASr: REGISTRATION FOR ABOVEGROUND SI'ORAGE TANK(S) * -

Page: 3 V. REGIS1'RATION / NOTIFICATION TYPE: (Fill in all circles that apply)

A.

• Initial Registration (New or existing AST/facility)

B. 0 Renewal Registration (Due to title transfer/ S year reporting requirement)

C. 0 Amended Notification (Converted, upgraded, repaired, or replaced AST)

D. 0 Closure Notification (femporary or permanent closure)

E.. :Number of Abovegro~ Storage Tanks (ASTs at this facility): (example:0001) I OI () I 2....I \ I F. Number of Tank Information Sheets attached (ASTs only): (example:0001) I QI OI D I \ I G. Number of Underground Storage Tanks (USTs) at the facility: (example:0001) I O I (.) I u I LI VI. OWNER 1YPE: (Fill in one circle only)

A. 0 Local Government B. 0 State Government C. 0 Federal Government D. e Commercial E. 0 Private VII. INDIAN LANDS: (Fill in all circles that apply)

A. 0 Tanks located on an Indian Reservation or on trust lands.

B. 0 Tanks owned by Native American nation, tnbe or individual.

C. Specify Native American tnl>e or nation (specify on page 9).

VIII. F ACIUTY TYPE: (Fill in all circles that apply)

A. 0 Gas Station/Convenience H. 0 Railroad N. 0 Trucking/Transport B. 0 Petroleum Distn'butor I. 0 Federal: Non-Military 0. e Utilities C. 0 Air Taxi (Airline) J. 0 Federal: Military P. 0 Residential D. 0 Aircraft Owner K. 0 Commercial Q. 0 Farm E.

• 0 Auto Dealership L. 0 Industrial R. 0 BuUc Storage F. 0 Local GovQrnment M. 0 Contractor s. 0 Other (Specify on page 9)

G. 0 State Government IX. TOT AL STORAGE CAPACITY OF FACIUTY: (Fill in all circles that apply)

A.

• Individual AST with capacity greater than 660 gallons.

B. I Facility with total capacity greeter than 1,320 gallons.

C. fl Facility with total capacity greater than 25,000 gallons.

D. 0 Facility with total capacity greater than or equal to 1,000,000 gallons.

E. ::~~~=~9~f  ::=ons: -1 i) ID 1~ lo Iz 17 I1 I lf j .2-j 7 j F. If facility is 25,000 gallons or greater, include Oil Discharge Contingency Plan facility identification number:

IFI c I- [Eli] - \3 Is i3 ls i X. F ACILl1Y SAFE FlLL AND SHUI'OOWN PROCEDURES: (Fill in all circles that apply)

A. Method of monitoring transfer operations:

1. e Manual 2. 0 Automatic II I

DEQ Form 7540-ASr: REGISl"RATION FOR ABOVEGROUND SfO~TANK(S} Page: 4 B. Typo of spill containmeot system at oil transfer arca.s where vehicle filling coonectioas arc ma.de:

1.

• Curbin& 4. 0 Nooe

2. 0 Drip Pans 5. 0 Other

3. 0 Sorbent Materials C. Automatic shutdown system locaied at the tank vehicle loading rack?

1. 0 Yes 2.

• No O. Collision barriers wed to protect pipe where vehicles are loading? -

1.

• Yes 2. 0 No XI. FINANCIAL RESPONSmIUTY (F'dl in all circles that apply)

A. I have ~ the financial responsibility requiremell15 in accordance with Sec. 62.1-44.34: 16 of the Code of Virginia utilizing the following method(s): {NOTE; This section is not applicable until VR 680-14-14 becomes effective.}

l.

• Self-Imurance S. 0 Surety Bood 8. 0 Va. Petroleum Storage

2. 0 Gurantee 6. 0 Letter of Credit - Tank Fuod (VPSTF)

3. 0 Trust Fund 7. 0 Risk Retei:t.ioo Group 9. 0 Not Applicable

4. 0 Commercial Insurance (Group Self*UIS'W'&llCO Pool)

B. Amount of financial responsibility requirements:

(example: 002000000; no com.mu) I I I I I *I I I l I C. Applicable registration fees must be submitted with 111y registration. Fees are explained below.

• NOTE: No (ee is required for a "notuacation" ror ASf coave~ion, upgrade, repair, replacement. or closure.

l. 0 One facility with one AST = $25 S. 0 Two or more facilities with two or more ASTs each= $100

2. 0 One facility with two or more AST1 = $SO 6. 0 Threo facilities with one AST each = $7S

3. 0 Two facilities with ooe AST each = $50 7.

• Three facilities with two or more ASTs a.t tho first

4. 0 Two facilities with ODO AST at tho tint facility m:i two facility and ooe AST at each other facility = $100 or more at the other =- $75 D. Application ree !or "regjstratioa" is attached '!

1.

• Yea 2. 0 No Malco check or mrm: order pgyabte to; Commoawtallh ol Viriinia, Department of Environmental Quality.

(lf rep.,tration fee oot enclosed, explain on paie 9.) MaiJ.ini Address: P.O. Box 11143, Richmond VA 23230-1143 I

I I

I II ,1 I

I

11*.-~

29345

• STATE USE ONLY DEQ Form 7~ASI': REGISTRATION FOR ABOVEGROUND STORAGE TANK(S)

FAC:.10.  !

I__.i - ~_.........___ ...;,..__

Pa.ae: 5 TANK INFORMATION (Complete all tank shoet.s for each tank al this location)

XII. DESCRIPTION OF ABOVEGROUND TANKS: (Fill in all that apply)

A. OWNER'S TANK IDENTIF1CA110N NUMBER:

(Exampla: 000001; IIO ~ )

~-1~-i-f-\9-\ T-.-\Jc._\_Il..4'. /-,/ ,:. , 9tJ-IJFO-T,'(-(.

B. TANK STATUS:

l-4J,~ ..../ llcJ kl .S- 1'78S~

1. e New Imtallation 4. 0 Repaired 7. 0 Change in Service

2. 0 CWTeDtly iD Use S. 0 Converted 8.0 Temporarily Out ofU_se

3. 0 Uppde 6. 0 Replacement 9: 0 Permanently Out of Use

c. INSTALLATION DATE (MMDDYY): Io I ~, o I /I1 ls l D. TOTAL STORAGE CAPACI1Y OF TANK rm aaJ]ons) IO IO I OI ol /*I :J.. I1 !-1 I E. TANK MATERIAL OF CONSTRUCTION:

1.

• Painted/Ban Sin1lo-walled Steel 6. 0 Lined Interior 11.0 Epoxy Coated Steel (Internal)

2. 0 Cathodi,:ally Protected Steel . 7. 0 Double-Walled 12.0 Epoxy Coa.ted Steel (External)

3. 0 Compoai.te(Steel wlFiber&lus) 8. 0 Double Bottomed 13.0 Unlcnown

4. *:J Ffuer&lasa Reinforced Plastic 9. 0 Coacrece 14.0 Other (Specify on Page 9)

S. : Insulated/Tanldacket 10. 0 Excav a.tion Liner F. FOUNDATION CONSTRUCTION MATDUAL:

1. 0 Eartheo Material 3. 0 Slee! S* .Q Unknown

2. ft Coocrete with Impermeable 4. 0 Coocrete wir.boUl 6. 0 Other Ma.terial Impermeable Material

. G. ROOF CONSTRUCTION n'PE:

1. 0 Floatiq Roof 4. 0 Double Deck Roof 7. 0 Lifter Roof

2. 0 Bolted Steel Cooo Roof S

• 0 Pontoon Roof 8. 0 Pan Roof .

3.0 Breather Roof 6. 0 Balloon Roof 9. S Other (Specify oo Paso 9)

B. PIPING TYPE:

1.0 Below Ground Pipea 2. <'tl Above Ground Pipes 3.(, Both I. PIPING CONSTRUCTION MATERIAL:

1. () Bare Steel 4. 0 Ffuer&lasa Reinforced Phutic 7.0 Unknown

2. 0 Galvani.zed Slee! S. 0 Double-walled 8.

• Other (Specify oa Pa1e 9) 3.0 Copper 6. 0 Secocdary Containmeel J. TANK CAmODIC PROTECTION:

I 1.e Nooe 2. 0 Sacrificial Anode(s) 3. 0 Impressed Curreu .

II

~*---~ 29345 DEQ Form 7~AST: REGISTRATION FOR ABOVEGROUND STORAGE TANK(Sl

• II Paae: 6 TANK INFORMATION (Complete all tank sbeeu for each tank at this location)

K. TANK CONTAINMENT AND/OR DIVERSIONARY STRUCTURES OR E_QUIPMENT:(Fill in all circles that apply)

1. :, Curbini 4. 0 Culverts &Dd/or Gutters 7. f Dikes1Berms/Retainin1-Walls

2. :) Weirs and/or Booms S. 0 Spill Diversion Pools 8. 0 Unknown

3. .:) Sorbeat Materiala 6. 0 Retention Ponds 9. 0 Other (Specify on Paee 9) 1- RELEASE PREVENTION BARRIERS:

1. :, Double Bottom 4. 0 Polyethylene Jacket 7. 0 Uoknown 2.8 Doub~walled S. 0 Excavation LizJer 8. 0 Other (Specify on Paae 9) *

3. :'.) I...ined Interior 6.

• Nooe M. .RELEASE DETECTION METHOD:

l. 8 Groundwater Moaitorin1 3. O Vapor MonitoriDs S. 0 None

2.

• Visual Moaitorin& 4. 0 ln1enlitw MooitoriD& 6. 0 Other (Specify on Paae 9)

N. TANK SAFE FILL AND smn"DOWN PROCEDURES:

1. Does tank have a 1aup measurm1 liquid level of tank?

L *Yes b. 0 No

2. Date puge was last c:&lJbrated: (MMDDYY)

• 3. Hiab level alarmed iDstalled?

Le Yes b. ::-> No

4. Type of high level alum:

L O Visual b. 0 Audibl.e c. e Both O. AST AND FACIIJn' INSPECTIONS:

(NIA

• Not appl.icable; N/C

• Not cooducted; Uok

• Unlcnowo: Dai.

• Date i.mpected)

Information Requested NIA N/C Unk Date (MMDDYYl .

1. La.st cal.hodic protectioo evaluatioa for AST. 0 a 0 I I I' i I

2. Last formal exten:w tank i.mpectioa. 0 0 0 I~ 1~ IQ Ir l, 5

3. Last formal external tank re-i.mpectioll.

4. Last formal internal tank inspection.

(I 0

0 0

• 0 I I I I Io ls l311 h s:

S. Last formal internal tank re-i.mpec:tioa. @ 0 0 I I ! I i.

II I

, ~11.--*~

29345 DEQ Form 7540-AST: REGISTRATION FOR ABOVEGROUND STORAGE TANK(S)

• P:iae: 7 II

,---------------------------------------- TANK INFORMATION (Complete all tank sheets for each tank at this locatio11) \A

~ ('-,) \ ..,.,..\\. rl Y-\

1 SI A N/C Unk Date (MMDDYY)

6. Lut hydrostatic testin& for pipin1. ~ 0 I

7. Last corrosion pro<ectioa for abovelf'OW)d pipin&* f- 0 lols ;J I I '. '1 :c

~

8. Lut cathodic protection for uodet'J1"ClUDd pipin&.

~

• I I i I

9. I..ut benn or dike evaluation or cartific:atioa by a professional eoJi,neer.

~

~ I I i ! I

10. Hu AST bad any major repairs or alteratiom? If yes, specify oo pa&e 9.

LO Yea b. I No P. SUBSTANCE CURRENTLY OR LAST STORED IN TANK:

l. C Guolino 5.0 Fuel Oil 9. Q Bunker *c*

2. ii Diesel Fuel 6. 0 Kerosene 10. J Jet Fuel

3. C) Guohol 1. ':) Used Oil 11.: Aviation Gasolioe /

4. 0 Heat.in& Oil 8. 0 Lubricatia& Oil 12. ~ Other (Specify oo Page 9)

Q. TEMPORARY OR PERMANENT TANK CLOSURES:

1. Type:

L O Temporuy closure b. 0 Pennaneal closure

2. Date tam: wu wt w<catioal A~ OWNER'S TANK IDENTIFICATION NUMBER: (example: 000001: ao commas)

B. Imtaller certified by tank and pipiD& mamfacturers?

1. 0 Yea 2. 0 No C. Installatioa inspected by repstered enpeer?

1.

• Yea 2. 0 No D. Installatioo compleeed to which st.aadanl?

1. 0 API 650 3. 0 API 620

2. 0 UL 142 4. 0 Other (Specify oa Pase 9)

E. Mamlfacturor's installatioa cbecklist(s) have been completed?

1. 9 Yes 2. 0 No F. "Certificata of Use" issued by local permittiD1 official?

1. 0 Yes 2*

• No II II

' 20208 STATE USE ONLY FAC.10 I I

.-........~-- .........--,

I DEQ Form 7540-AST: REGISTRATION FOR ABOVEGROUND STORAGE TANK(S) Pqe: 9

---

, TANK INFORMATION xm. (continued) (Complete all tank sheets for ea.ch tank a.t this location)

G. OAm: / cerrify the informarion concerning installarion thaJ is pruvilkd in section XIII is mu to the best of nry belief and Jcnowudge.

lnstalJer Name:~c. .c.,g dZ e{JAme. Company Name::----1.l.....:~~04.=w:Ea";..:',c~Y--..::.4.__-'&_....~0(-.:;.:;;..qf=-

~ ~-i(y(

I c.rrify 1111JUr pma1ly of law thal I haw penona/Jy u.amiMd and am familiar wilJa IN infonnarion n,brniaed in dus and all a11QCMd doaunena. ONJ thal based on my inquiry ofthM* individllalr immediauly ruponsiblefor obtaining th4 informarion, I beij,,w thal tlw .rubmilUJ inforrnalion i.r rrw, acc,uau, and comp'611. .

(To be sianec:f by either the owner or tbe owners authorized represemadve).

Name and offldal title of o w n e r : ' - - - - - - - - - - - - - - - - -

Sip.stun: --------------Dalt:------

Name and otr&cial title of owner's authorized representative:

-*-""'-=-:\<...:::::.~-~~~\.....:_~.:.:..:..,.*--l:l~~~..::::..~.u,>,:~~~~:::U.:-~-+-~......;;'~'\ '{ ~\'.) ( °' '" "-~ "-,

l.1 l"\.S USE THIS SPACE TO vn. c-=.;*:..___ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

VIII.S..:...*------------------------------------

~ B~-------------------------------------

XL D;.,;*:..___ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

xn. E.=---------------------------------~--

xn. F..:...- - - - - - . . . . . - . . . . . - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

~: ~~*~~-*~\\.:::..~i,t\::::.... u,,...~~\.:,,..l~~~~~~~~~~~~~::~~~::::~~~::~::~::~~::~::~::~:::.

0l!,..,:.:::.::i;i!.,.....S::..J*~j:C>~\~~~~:~Q;..::.:X....;,r-..,..:...?,~

1 xn. IC.:..__ _ _ _ _* _ _ _ _ \.,l,.----------------------~-

xn. L-=---------------------------------------

xn. M : : . * - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

xn. P xn. <>.:..*- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

xm. o .__________________________________

ADDmONAL COMMENTS: - - - - - - - - - - - - - - - - - - - - - - - - - - - -

II II