COMPLIANCE INFO_1986-1996 - Laserfiche WebLink

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• • SpUaCfS rt • v. pp STATE OF CALIFORNIA P 9 STATE WATER RESOURCES CONTROL BOARD w UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. f°"N MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CL_O E ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED v DBA OR FACILITY NAME WHERE TANK IS INSTALLED: �j 0 /L F;q�C/G /T ,ei ///7-5- 1. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK 1.D. (/Llti�/nOur✓1 B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) S 3 D. TANK CAPACITY IN GALLONS: Q D� ILTANKCONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. 4US v A laR ❑ 3 DIESEL 1 MOTOR VEHICLE FUEL 4 OIL g, C. 6 AVIATION GAS 2 PETROLEUM 80 EMPTY 1 PRODUCT 1b PREMIUM ❑UNLEADED 4 GASAHOL ❑ 7 METHANOL 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.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM x 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE 7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING C.INTERIOR 5 GLASS LINING 6 UNLINED 95 UNKNOWN 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES NO D.CORROSION ❑ 1 POLYETHYLENE WRAP 2 COATING 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR ✓i h OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR)M,knowpi IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION AU02 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A6)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)AID 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 1009/6 METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION X 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 INTERSTITIAL MONIT ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING 6 TANK TESTING 7 INTERSTITIAL MONITORING 91 NONE ❑ 95 UNKNOWN 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND T THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAMEATE (PRINTED 8 SIGNATURE) �f c 4• / 't e.^'� LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW b� COUNTY# JURISDICTION# FACILITY# TANK# /L STATE I.D.# c ❑m 1 1 llsl5ly � O 2 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE / FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOR00368-RS 4