COMPLIANCE INFO_1987-1998 - Laserfiche WebLink

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STATE A °""; STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B s I o COMPLETE A SEPARATE FORM FOR,jjgTANK SYSTEM `•�•o��' MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 7 PERMANENTLY CLOSE ! REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED; 5p FaCi I I� I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN ( ! A. OWNER'S TANK 1.D.a ! !U i /t —01 S. MANUFACTURED BY: ! C. DATE INSTALLED(MO/DAY/YEAR) I,7�� D. TANK CAPACITY IN GALLONS; oWpl O IL TANK CONTENTS IFA-/IS MARKED.COMPLETE ITEM C. A. t MOTOR VEHICLE FUEL ❑ 4 OIL g_ C. to REGULAR-7-- U3 DIESEL 2 PETROLEUM NLEADED 6 AVIATION GAS ❑ ❑ >m EMPTY 9 1 PRODUCT ❑ tb PREMIUM �AHOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE F7 2 UNLEADED 5 JET FUEL ❑ 7 METHANOL DED F-1 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES INBOX D AND E A. TYPE OF ❑ 1 DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL 4 SECONDARY CONTAINMENT tr� NAUITED TANKy 99 OTHER B. TANK L_! 1 BARE STEEL 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD w/FIBERGLASS REINFORCED PLASTK: MATERIAL ❑ 5 CONCRETE ® 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 t00x METHANOL COMPATIBLE W/FRP (Primary Tank) j 9 BRONZE ❑ W GALVANIZED STEEL 95 UNppWN 99 OTHER C.INTERIOP 177 1 RUBBER LINED ❑ 2 ALKYD LINING 173 EPDXY LINING ❑ 4 PHENOLIC LINING LINING !❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100'x METHANOL 7 YES_ NO_ D.CORROSION LJ 1 POLYETHYLENE WRAP ❑ 2 COATING 3 VINYL WRAP ® 4 FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION 1-7 9/ NONE 95 UNKNOWN F —' ;J 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 1F UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U / SUCTION A2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U N OTHER C. MATERIAL AND A U t BARE STEEL A U 2 STAMaLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL w/COATING PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODC PROTECTION A U A U UNKNOWN A U 0 OTHER 6 1013% METHANOL COMPATIBLE W/FRP D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIG 4S TESTING O r-- A�ROR+dG �J 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK r 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ® 4 AUTOMATIC TANK GAUGING® 5 GROUND WA=L"4ONITORING J 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE95 UNKNOWN❑ ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) i 2.ESTIMATED OUANTITY OF SUBSTANCE REMAININGI WAS TANK FILLED WITH GALLONS INERT MATERIAL? YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT APPLICANTS NAME a Nno a sIGNATIlgQ • „ I , 4 „ DATE f i ^>�(►�� yr l rti. ,, Y a LOCAL AGENCY USE ONLY THE STATE LD.J NUMBERS COMPOSWO FgE FOUR NUMBERS BELOW STATE 01COUNTY It JURISDICTION IC FACILITY 6 TANK 6 C� m � U � � �,, y, PERMIT NUMBER PERMIT APPROVED BY/DATE I I PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM B (12.91) FILE THIS FORM WITH F"' AL AGENCY IMPLEMENTING THE UNDERGROUND STOW ANK REGULATIONS FORMS-%