COMPLIANCE INFO_1991-2004 - Laserfiche WebLink

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: STATE OF CALIFORNIA4 - STATE WATER RESOURCES CONTROL BOARDDEC 2 2 iG92 UNDERGROUND STORAGE TANK PERMIT APPLICg% At., HE. COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. PER MIT15r-til MARK ONLY 211 NEW PERMIT F7 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY ONE ITEM F7 2 INTERIM PERMIT F7 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVE DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN K� A. OWNER'S TANK I.D.* VPYB. MANUFACTURED BY: 116je- ,- I A&I__ C. DATE INSTALLED(MO/DAY/YEAR) 7- EAR) 1 1),Y D. TANK CAPACITY IN GALLONS: 11.TANK S2NTENTS IFA-1 IS MARKED,COMPLETE ITEM C. REGULAR A. [?5'1 MOTOR VEHICLE FUEL F74 OIL B. C. ❑ la UNLEADED 3 DIESEL ❑ 6 AVIATION GAS F7 2 PETROLEUM F7 80 EMPTY ❑ 1 PRODUCT ❑ 1b PREMIUM 4 GASAHOL 7 METHANOL UNLEADED El 5 JET FUEL LJ ❑ 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 �ID Wbe?vleo 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.8,AND C,AND ALL_THAT APPLIES IN BOXO AND E A. TYPE OF N?11"1 DOUBLE WALL F-] 3 SINGLE WALL WITH EXTERIOR LINER E 95 UNKNOWN SYSTEM F7 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) F-] 99 OTHER B. TANK 7] 1 BARE STEEL ❑ 2 STAINLESS STEEL �3 FIBERGLASS E:] 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE 6 POLYVINYL CHLORIDE 7 ALUMINUM 8 1009/6 METHANOL COMPATIBLEW/FRP (Primary Tank) 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER C.INTERIOR 1 RUBBER LINED ❑ 2 ALKYD LINING F73 EPDXY LINING ❑ 4 PHENOLIC LINING LINING .5 GLASS LINING ❑ 6 UNLINED 7 95 UNKNOWN ❑ 99 OTHER 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 a 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION Ao 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A(T 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A Loll FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELW/COATING A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER [��J�I D. LEAK DETECTION [�l AUTOMATIC LINE LEAK DETECTOR C?2 LINE TIGHTNESS TESTING MONITORING [::] 99 OTHER V.TANK LEAK DETECTION 1 VISUAL CHECK1�i,2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING [:] 5 GROUND WATER MONITORING 6 TANK TESTING Z"7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWNQ 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 SU�� GALLONS REMAINING INERT MATERIAL 7 _ THIS FORM HAS BEEN COMPLETED UNDE13,ffENA L TY OF PEqjUR_Y,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME DATE (PRINTED&SIGNATURE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FpU`R NUMBERS BELOW----' COUNTY# JURISDICTION# FACILITY# TANIK I In STATE 04 F C)C/ PERMIT NUMBER PERMILU AP AT (,PROVED BY/D IT EXPIRATION DATE FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•-reW**,-Uff1ESS A CURRENT FORM A HAS BEEN FILED. • • �j�j �3,j,L IG) W FOR00348-RS