COMPLIANCE INFO_1991-2004 - Laserfiche WebLink

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STATE OF CAUFOMQA STATE WATER RESOURCES CONTROL BOARD 4 6 UNDERGROUND STORAGE TANK PERMIT APPLICATION FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION F7 7 PERMANENTLYCL SITE ONE ITEM ❑ 2 INTERIM PERMIT F-14 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE F] 8 TANK REMOVE M, DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Q\ewron (AS R 6 0 f 5-f 7A6,41, 76 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK 1.D.# a_ I S. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) D.TANK CAPACITY IN GALLONS: /---f 000 H.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. C. E:] la REGULAR 1 3 DIESEL 6 AVIATIONGAS A. I MOTOR VEHICLE FUEL ❑ 4 OIL B. UNLEADED 7 METHANOL 4 GASAHOL So EMPTY I PRODUCT F--j 2 PETROLEUM lb-A 10 UNLEADED 5 JET FUEL ❑ 3 CHEMICAL PRODUCT Q 95 UNKNOWN 0 2 WASTE E:] 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A-1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.s: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.S.AND C.AND ALL THAT APPLIES IN BOX 0 A. TYPE OF 191 1 DOUBLE WALL F-1 3 SINGLE WALL WITH EXTERIOR LINER F--] 95 UNKNOWN SYSTEM F--j 2 SINGLE WALL F-j 4 SECONDARY CONTAINMENT (VAULTED TANK) [] 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL )—<3 FIBERGLASS AN 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE F❑�6 POLYVINYL CHLORIDE 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) E:] 9 BRONZE ❑ 10 GALVANIZED STEEL [::] 96 UNKNOWN ❑ 99 OTHER F-1 1 RUBBER LINED 2 ALKYD LINING F--] 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR 6 GLASS LINING ❑ 6 UNLINED F-1 95 UNKNOWN ❑ 99 OTHER UN114G IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO— D.CORROSION ❑ i POLYETHYLENE WRAP E] 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION 0 5 CATHODIC PROTECTION [::] 91 NONE E:]95 UNKNOWN E::] 99 OTHER IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE AN I SUCTION Ar 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U I SINGLE WALL A@ 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®4 FIBERGLASS PIPE CORROSION A U 6 ALUMINUM A U 6 CONCRETE A U 7 STEEL WI COATING A U 8 100% METHANOL COMPATIBLeW/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER IML 0 99 OTHER D. LEAK DETECTION X 1 AUTOMATIC LINE LEAK DETECTOR D 2 LINE TIGHTNESS TESTING [] 3 MNOTERSTNFTORING V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATION F--j 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING 0 5 GROUND WATER MONITORING L❑ 6 TANK TESTING 7 INTERSTITIAL MONITORING 91 NONE ❑ 95 UNKNOWN Ej 99 OTHER Z®r 7 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 7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OKp—EP3bQY,AOCTO�Hf?qE\S (X MY 007INLEDGE,IS TRUE AND CORRECT DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR MBERS 840W COUNTY# JURISDICTION# Foc—fry—#"�, - TANK# STATE 1.1311 1 o0 �-—114 5TN �6 a PERMIT NUMBER PERMIT APPROVED,BY/DATE XPIRATION DATE 4 FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED.