COMPLIANCE INFO_1986-1996 - Laserfiche WebLink

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• STATE OF CALIFORNIA • STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B GUMFLtl t A StNAHAI t I'UHM YUH H TANK SYSTEM. MARK'ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT oe 5 CHANGE OF INFORMATION ❑ 7 ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: AP -Lo 1p'FAC_ "o. o Sy 8 I. TANK DESCRIPTION COMPI FTF Al I ITEMS - SPECIFY IF 11NKNOWN A. OWNER'S TANK 1. D. 4 S 1!, B. MANUFACTURED BY: V N414oa 0 w )-4"w V C. DATE INSTALLED (MO/DAY/YEAR) 05 ,/ wo 0. TANK CAPACITY IN GALLONS: rJr�O II. TANK CONTENTS IFA -1 IS MARKED. COMPLETE ITEM C_ v A. ❑ 1 MOTOR VEHICLE FUEL �4 OIL B. REGULAR ❑ 3 DIESEL I-:].6 AVIATION GAS C. 1:11aUNLEADED ❑ 2 PETROLEUM ❑ 80 EMPTY F71 PRODUCT ❑ lb PREMIUM ❑ 4 GASAHOL 1:1 7 METHANOL UNLEADED F79JET ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 WASTE � ❑ 2 LEADED ©/ OTHERL(DESCRIBE IN ITEM D. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED V S E O "o -To Z OIL— C. A. S. III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN ROXFS A R AND C AND Al I TWAT APPI IFR IN RDY n ANn P A. TYPE OF LJ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ©"2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK [2"l 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100°/6 METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 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 [;?I6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO D. CORROSION ❑ 1 POLYETHYLENE WRAP I❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION I❑ 91 NONE Flw-;�T5 UNKNOWN ❑ 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 IF UNDERGROUND ROTH IF APPI ICARI F A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A(T) 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN AQ 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 /0 CATHODIC PROTECTION 3 POLYVINYL CHLORIDE (PVC)A U 4 FIBERGLASS PIPE 7 STEEL W/ COATING A U 8 100°/ METHANOL COMPATIBLE W/FRP A U 95 UNKNOWN A(2)99 OTHER V jo, > D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 IMTE S RI IA [?'99 OTHER hl V. TANK LEAK DETECTION �1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORINC ❑1iI'6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI. TANK CLOSURE INFORMATION 1. ESTIMATED DATE LAST USED (MO/DAY/YR)I 2. 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 APPLICANTS NAME DATE (PRINTED 8 SIGNATURE _4C QMAz•zt •gZ LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPO OF THE FOUR NUMBERS BELOW C COUNTY # JURISDICTION # FACILITY # TANK # (�f STATE I.D.# �, I >I -1 i V t 3ERMIT NUMBER i PERMIT APPROVED BY/DATE I PERMIT EXPIRATION DATE FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORM A, UNLESS A CURRENT FORM AAA HAS BEEN FILED. FOR00348-RS