COMPLIANCE INFO_1986-1996 - Laserfiche WebLink

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I STATE OF CAUFORMA STATE WATER RESOURCES CONTROL 130ARD ' 4,1G fix.,i UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM H COMPLETE A SEPARATE FORM FOR TANK SYSTEM. = ' MARK'ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL.PERMIT1�9-/S CHANGE OF INFORMATION Fj 7 PEAMAN SE CN „E ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ❑ 8 TANK DBA OR FACILITY NAME WHERE TANK IS INSTALLED: jc�e4,p '=qL_ u 0. OEL4 8 I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN v l� A. OWNER'S TANK I.0.0 L4-UISL- P I 3, -MANUFACTURED BY: V1.4W,1.1Q�� C. DATE INSTALLED(MO(OAYNEAR) CIS/ -//y(Q I 0. TANK CAPACITY IN GALLONS: &I Coo II.TANK CONTENTS IFA-I IS MARKED,COMPLETE ITEM C. A. F_-;;?'l MOTOR VEHICLE FUEL ❑ 4 OIL 8. C- I 1iUNLEUADED 3DIESEL -3AVIATICN GAS 2 PETROLEUM ❑ 30 EMPTY 211-1 PRODUCT ,-'b PREMIUM i4 GASAHOL - -METHANOL UNLEADED 5 ET FUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE L 2 LSAOED 99 OTHER (DESCRIBE IN ITEM 0. Bt cwt 0: IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.a III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.S.AND C.AND ALL THAT APDL IES IN BOX D AND E A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM =wr,2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK =1.1-1 RARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W1 FIBERGLASS REINFORCED PLSST!C MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPAT18LE WiFXP (Primary Tank) ❑ 9 SRONZ ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENCL.'C LINING C.INTERIOR 5 GLASS LINING ' * UNLINED LINING ❑ ^ �I 95 UNKNOWN ❑ 99 OTHER IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO_ D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING !1 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHOOIC PROTECTION ❑ 91 NONE =wf-Z UNKNOWN ❑ 99 OTHER - { E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) 1 IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U I SUCTION An 2 PRESSURE A U 3 GRAVITY A U 99 OTHER 9. CONSTRUCTION A U 1 SINGLE waLL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND AID 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHL.ARIOE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U B CONCRETE A U 7 STEEL.WI COATING A U S 100% METHANOL COMPATIBLE WiPRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHOOIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D, LEAK DETECTION ER-i AUTOMATIC LINE LEAK DETECTOR 7,rt LINE TIGHTNESS TESTING 3 16 MONITORING l"EF ❑gg OTHER V.TANK LEAK DETECTION 1✓1'1 VISUAL CHECK F-1 2 INVENTORY RECONCILIATION ❑ 3 VAOOM MONITORING ❑ 4 AUTOMATIC TANK GAUGING❑1 5 GROUND WAT=A MONITCRING CVro TANK TESTING ❑ 7 INTEASTITLALMONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/OAY/YR) I 2 ESTIMATED QUANTITY OF I 1 WAS TANK FILLED WITH YES NO SUBSTANCE REMAINING GALLONS INERT MATERIAL THIS FORM NAS SEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE SaF T OF MY KNOWLEDGE, IS TRUE AND CORP.ECT APPUCANTS NAME (PRINTED&SIGNATURE) DATE A -Z-74-Q Z LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OFTHE FOCIR NUMBERS BELOW ? - W r COUNTY x JURISDICTION x FACILITY x T NK x 1 17 STATE LD. (� C� I t I i )I i !I 0I PERMIT NUMBER i PERMIT APPROVED BYIDATE I PERMIT EXPIRATION DATE ;:CRM B (7.91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOFOOSiB-n5 V