COMPLIANCE INFO_1991-2000 - Laserfiche WebLink

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t • � � C90UHCE3 STATE OF CALIFORNIA P V cc�i STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B • C�(,FON N�. COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT E] 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN ' B. MANUFACTURED BY: OWNER'S TANK I.D.# A.LC. OATS INSTALLED(MO/DAYINEAR) D. TANK CAPACITY IN GALLONS: 2o II.TANK CONTENTS IFA-11SMARKED,COMPLETE ITEM C. to REGULAR ❑ 3 DIESEL ❑ 6 AVIATION GAS A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. J 1 PRODUCT C Q tb PREMIUNLEADE ❑ 4 GAS ❑ I�V71( 7 METHANOL ❑ 2 PETROLEUM ❑ EMPTY UNLEADED ❑ 5 JET FUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.# 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C,AND ALL THAT APPLIES IN BOX D ❑ 1 DOUBLE WALL F-� 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN A. TYPE OFO 99 OTHER SYSTEM 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 6 POLYVINYL CHLORIDEV95 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP MATERIAL ❑ 5 CONCRETE (Primary Tank) E] 9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED F7 2 ALKYD LINING 7 3 EPDXY LINING 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED �95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 1009:METHANOL? YES_ NO_ ❑ 1 POLYETHYLENE WRAP 2 COATING VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC D.CORROSION 5 UNKNOWN ❑ 99 OTHER PROTECTION O 5 CATHODIC PROTECTION ❑ 91 NONE IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE ;w SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B, CONSTRUCTION A U i SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100°/ METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION Y-u0'95 UNKNOWN A U 99 OTHER ❑ 3 INTERSTITIAL 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING MONITORING ❑ V.TANK LEAK DETECTION ❑ ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING El 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES (� NO t.ESTIMATED DATE LAST USED(MOlDAY/YR) SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT DATE APPLICANTS NAME (PRINTED 8 SIGNATURE) 7�1 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY#3q6 TANK# STATE I.D.# F= -5 PERMIT NUMBER PERMIT APPROVED BY/DATE AM ;F /+ FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FOR A HAS BEEN �OR00346•R4 FiJc 7 /�'�� 011 Q