COMPLIANCE INFO_1986-1996 - Laserfiche WebLink

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- • • i.su�Rces STATE OF CALIFORNIA z `' STATE WATER RESOURCES CONTROL BOARD _ UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B � a �> COMPLETE A SEPARATE FORM FORE CH TANK SYSTEM. MARK'ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANE ED ON E ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑ 8 TANK M j DBA OR FACILITY NAME WHERE TANK IS INSTALLED: IAP-4-0 7;-AC_ K10. 05L48 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK 1.D.# / 1,_tJ�f_�Q. I B. MANUFACTURED BY: l..)}4v)"014� J C. DATE INSTALLED(MO/DAY/YEAR) d S /_ /�4 D. TANK CAPACITY IN GALLONS: 4�Q ILTANKCONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A. [ MOTOR VEHICLE FUEL ❑ 4 OIL B. C. E�j ela REGULAR ❑ 3 DIESEL ❑ 6 AVIATION GAS UNLEAD ❑ 4 GASAHOL ❑ 2 PETROLEUM ❑ 80 EMPTY Ft.�'1 PRODUCT ❑ lb PREMIUM 7 METHANOL DED ❑ 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.,v: 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 ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM [2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK 1211 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100°/ METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED F72 ALKYD LINING F73 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING [;?"'S UNLINED ❑ 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 [2'g5 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION AID 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION Aol SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER I C. MATERIAL AND A(D 1 BARE STEEL A U 2 STAINLESS 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 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 7 ' AUTOMATIC LINE LEAK DETECTOR 7,'j"2 LINE TIGHTNESS TESTING ❑ 3 INTERSTITIAL ❑99 OTHER V.TANK LEAK DETECTION ❑i�1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑� S TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF3.WAS TANK FILLED WITH YES ❑ NO SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (P RINTEDm&SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR 416MBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE LD.#. Z711 V,l/q PERMIT NUMBER PERMIT APPROVED BY/DATE I PERMIT EXPIRATION DATE I W_ FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORMA,UNLESS A CURRENT FORMA HAS BEEN FILED. FOR00346-RS