COMPLIANCE INFO_FILE 9 - Laserfiche WebLink

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STATE OF CALIFORNIA, STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B w ° K o , COMPLETE A SEPARATE FORM FOR EACH K SYSTEM. ;. MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL N IT ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: f2i 94tA ,,, I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# f3ld'61, B. MANUFACTURED BY: fin C. DATE INSTALLED(MO/DAY/VEAR) D. TANK CAPACITY IN GALLONS: II.TAN ONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL F74 OIL B. C. ❑ 1aUNLEADED - 3 DIESEL U 6 AVIATION GAS 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ lb PREMIUM 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 NOTMARKEO,,ENTER NAME OF SUBSTANCE STORED C.A.S.#: III. TANK CONSTRUC N 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 F-12 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER_ Aq �.:1 BARE STEEL 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLQ�S REINFORCED PLASTIC L B. TANK MATERIAL ❑ 5 CONCRETE F—] 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) 09 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING ❑ 1 RUBBER LINED ❑ Y (- C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 NOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES NO s6 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) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAS _ ` IV.PIPING INFORMATION CIRCLE A IFABOVEG UNDOR U IF UNDERGROUND,BOTH IF APPLICABLE .w A. SYSTEM TYPE A U 1 SUCTION U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 "OWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) U 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 A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING 3 INTERS I IAL gg OTHER ❑ ❑ MONRORING ❑ 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 FESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? I THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED&SIGNATURE) - -fir k ,, LOCAL AGENCY USE ONLY THE STATE I.D.NUM13ER IS COMPOSED OF THE FOUR NUMBERS BELOW 3 p€; COUNTY# JURISDICTION# FACILITY#. TANK# L STATE I.D �- (El PERMITNUMBER PERMIT APPROVED BY/DATE PERMIT E ATIONDATE 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 STORAGE TANK REGULATIONS �ORkA B (12.91) • FOR00346•R6 7 �"F°