COMPLIANCE INFO_1989-2001 - Laserfiche WebLink

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0 'r a,"^ ^v STATE OF CALIFORNIA ." STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM Bao 0 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ® 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL ON SI ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOV J� DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ('��:p. q Z7 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.III B. MANUFACTURED BY: .f1S C. DATE INSTALLED(MO/DAYNEAR) I q�, D. TANK CAPACITY IN GALLONS: (Z 000 ILTANKCONTENTS IFA•1ISMARKED.COMPLETE ITEM C. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. I C. © laREGULUNLEADR 6 AVIATION GAS ❑ 3 DIESEL ❑ A. 2 PETROLEUM ❑ 80 EMPTY a 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 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 I 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL 0 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 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 U 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAPXl 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(YEAR) I _ IV.PIPING INFORMATION CIRCLE A IFABOVEGROU_NOOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE SUCTION A,16-,? PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION U 1 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)Alto 4 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 idONERSTI IAITOR ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ® 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING 0 5 GROUND WATER MONITORING ❑ 6 TANK TESTING X 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN u 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 i❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY RJURY, D O T F MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED d SIGNATURE) f II1 —. .lb SAN LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OFTH FOUR UMBERS q�LOWvi ' COUNTY# JURISDICTION# I FA ITY#003 If TANK# STATE LD.# - i d a I �►� PERMIT NUMBER fPERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE z d G/b THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILECIf FILE THIS FORM WITH TWOCAL AGENCY IMPLEMENTING THE UNDERGROUND STO�E TANK REGULATIONS FORM B (12-91) ro��5 n FOR00948 R6