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 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. SpURCE P� SCO P 7s n _ y ML m MARK'ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT �5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSE(k ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: %q 24.0 FFV-- r l O. o5y a MATERIAL I. TANK DESCRIPTION COMPLETEALL ITEMS -- SPECIFY IF UNKNOWN A. OWNER'S TANK I. D. # ��'� B. MANUFACTURED BY: V �K� C) w kj C. DATE INSTALLED (MO/DAY/YEAR) Q S / /�� D. TANK CAPACITY IN GALLONS: y Qoo II. TANK CONTENTS IFA -1 IRMARKFnr.nMPIPTP ITFMr ry A. MOTOR VEHICLE FUEL ❑ 4 OIL B. REGULAR 3 DIESEL 6 AVIATION GAS C• 2 PETROLEUM ❑ 80 EMPTY ©-1 PRODUCT UNLEADED a lb PREMIUM ❑ 4 GASAHOL 7 METHANOL UNLEADED 5 JET FUEL 3 CHEMICAL PRODUCT F-] 95 UNKNOWN 2 WASTE E] 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 ONF ITFM ONI Y IN ROXFS A R Ar -in r ANn Al I TWAT APPI IFC IN any n ANn c A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK E;4 -*l BARE STEEL ❑ 2 STAINLESS STEEL F73 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 AUTOMATIC LINE LEAK DETECTOR E1 LINE TIGHTNESS TESTING ❑ 3INTERSTITIAL99 F-]1 RUBBER LINED ❑ 2 ALKYD LINING F--]3 EPDXY LINING F-]4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING ©'16 UNLINED F-195 UNKNOWN ❑ 99 OTHER LINING -- -. 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 ERfI5 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 AQ2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A(D 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND CORROSION PROTECTION Ag 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) A U 7 STEEL W/COATING A U A U 95 UNKNOWN A U 4 FIBERGLASS PIPE 8 100°/ METHANOL COMPATIBLE W/FRP 99 OTHER D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR E1 LINE TIGHTNESS TESTING ❑ 3INTERSTITIAL99 MONITORING ❑ OTHER V. TANK LEAK DETECTION �1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING a 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING [j�/6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN a 99 OTHER VI. TANK CLOSURE INFORMATION 1. ESTIMATED DATE LAST USED (MO/DAY/YR) 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) LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE I.D.# COUNTY # JURISDICTION # FACILITY # TANK # � 1�n I I I � I I I- 'ERMIT 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. FOR0034B-115