COMPLIANCE INFO_1986-1995 - Laserfiche WebLink

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�� 1 .� x n��• �'�' +� � �� a� A .r.t�J 3 � ➢ w ,a as^ !. � T`' '{V'S p,sourzces c STATE OF CALIFORNIA 9 STATE WATER RESOURCES CONTROL BOARD- UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B ;� COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSER..QN SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: �j G, ,r-, 1, C k,12 I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK 1.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN LONS: i ILTANKCONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. to REGULAR ❑ 3 DIESEL A. ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. UNLEADED ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT tb PREMIUM ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 UNLEADED EADED ❑ 99 JOTHERL(DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.A III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL T'AT APPLIES IN BOX D AND E A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTE IOR LINER ❑ 95 UNKNOWN SYSTEM F--12 SINGLE WALL F14 SECONDARY CONTAIN NT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS F-14 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL F—] 5 CONCRETE F—] 6 POLYVINYL CHLO E F-] 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED S EL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING , C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED-r ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COA-fING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 ONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLS (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOV ROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER x B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 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 100Y METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZ STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMAT LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 MHOTER ORING ❑99 OTHER V.TANK LEAK DETECTION [Tj 1 VISUAL CHECK ❑ 2 VENTORY RECONCILIAT,IOpX�' ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ INTERSTITIAL MONITORING 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFIAMATION 1.ESTIMATED DATE LAST UD(MO/DAY YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH r� SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES ❑ NO ❑ THIS FORM HASEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT$NAME DATE (PRINTED 6 y9(GNATURE) f LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW P lz 2 3 - COUNTY# JURISDICTION# FACILITY# WANK# STATE LD.# ❑m ..,. PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE II 9 THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND ST GE TAN{K RE ULATIP S FORM B (12-91) t..�/ ��i -', l N FOR0034B-R6