COMPLIANCE INFO_1987-1998 - Laserfiche WebLink

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• � soonces STATE OF CALIFORNIA PG°> STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM Ba° COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON J ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED ' DBA OR FACILITY NAME WHERE TANK IS INSTALLED: J3 10 L >9G 1 L 1 % Y -#- I. TANK DESCRIPTION COMPLETE ALL ITEMS -- SPECIFY IF UNKNOWN A. OWNER'S TANK I. D. #no B. MANUFACTURED BY: C. DATE INSTALLED (MO/DAY/YEAR) 17841D. TANK CAPACITY IN GALLONS: O QQO II. TANK CONTENTS IF: A-11SMARKFnCOMPIPTP ITFMC A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL e, C ❑ 1a REGULAR ❑ 3 DIESEL ❑ 6 AVIATION GAS F-]2 PETROLEUM E::]80 EMPTY 1 PRODUCT UNLEADED ❑4 GASAHOL j j 1b PREMIUM E] 7 METHANOL 3 CHEMICAL PRODUCT 95 UNKNOWN ❑ 2 WASTE i UNLEADED ❑ 5 JET FUEL ❑ 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 r)NF ITEM nNl Y IN RnXFR A R ANn r. ANn AI I TWAT ADDI ICC IN DnV n —11 A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM x 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK F—]1 BARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE F-� 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN F—] 99 OTHER 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING 3 F—]1 RUBBER LINED F—]2 ALKYD LINING ❑ 3 EPDXY LINING F-]4 PHENOLIC LINING C. INTERIOR F--]5 GLASS LINING � 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 1005/6 METHANOL? YES_ NO— D. CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER //,, E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) a OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR)k ChCI(il►j IV. PIPING INFORMATION CIRCI F A IF AROVF rRnl INn nR II IC I immme-Gni INn DnTW IC ADDS 1-1 c A. SYSTEM TYPE A U 1 SUCTION AU 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH AID 95 UNKNOWN A U 99 OTHER C. MATERIAL AND CORROSION PROTECTION A U A U A U 1 BARE STEEL 5 ALUMINUM 9 GALVANIZED STEEL A U A U A U 2 STAINLESS STEEL A U 6 CONCRETE A U 10 CATHODIC PROTECTION 3 POLYVINYL CHLORIDE (PVC) AG 7 STEEL W/ COATING A U A U 95 UNKNOWN A U 4 FIBERGLASS PIPE 8 1009/6 METHANOL COMPATIBLE W/FRP 99 OTHER D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING 3 MONITORING ❑ 99 OTHER V. TANK LEAK DETECTION FlX^--j 1 VISUAL CHECKFIV 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING❑5 GROUNDWATER MONITORING 6 TANKTESTING F—]7 INTERSTITIAL MONITORING ❑ 91 NONE E:]95 UNKNOWN E:]99 OTHER VI. TANK CLOSURE INFORMATION 1. ESTI)VD D E LAST USED (MO/DAY/YR) F2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES ❑ NO ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME —� (PRINTED 8 SIGNATURE) . DATE 9a LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW to f COUNTY # JURISDICTION # FACILITY # TANK # STATE IBM COUNTY 13 a ! A PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION . FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. • � (�.� R B•RS