COMPLIANCE INFO_1993-1998 - Laserfiche WebLink

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C Yom';:,:',{' '.:"„; i'.v�d:.tii.r,f><:.:.: s. SOURCES STATE OF CALIFORNIA • PG c° STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B ° irk COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM A. OWNER'S TANK 1. D. # B. MANUFACTURED BY: C. DATE INSTALLED (MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: 12, oo MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLO ONSITE ONE ITEM ❑ 2 INTERIM PERMIT a 4 AMENDED PERMIT [::] 6 TEMPORARY TANK CLOSURE a 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 101N ))'1'?a (-r y . zAbs �U ❑ 6 POLYVINYL CHLORIDE I. TANK DESCRIPTION COMPLETE ALL ITEMS -- SPECIFY IF UNKNOWN (Primary Tank) ❑ 9 BRONZE A. OWNER'S TANK 1. D. # B. MANUFACTURED BY: C. DATE INSTALLED (MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: 12, oo II. TANK CONTENTS IFA -1 IS MARKED, COMPLETE ITEM C. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL ✓� 1` PRODUCT C ❑"lia REGULAR ❑ 3 DIESEL ❑ 6 AVIATION GAS UNLEADED lb PREMIUM El4 GASAHOL ❑ 2 PETROLEUM F-] 80 80 EMPTY SYSTEM ❑ 7 METHANOL UNLEADED 0 JET L 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. #: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES k. B. ANDC. AMID ALLTFTAT APPLIES IN BOX D AND F A. TYPE OF ET 1 DOUBLE WALL Q 3 SINGLE WALL WITH EXTERIOR LINER a 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑' 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK F-]1 BARE STEEL El STAINLESS STEEL 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 F-1 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING [2UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES NO D. CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) E+ IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 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 A U 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) 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 [2-1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 MONITORING ❑ 99 OTHER V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORINC 6, TANK TESTING 'P INTERSTITIALA6MTORING :91 NONE Q 95 UNKNOWN ❑ 99 OTHER VI. TANK CLOSURE INFORMATION 1. ESTIMATED DATE LAST USED (MO/DAY/YR) 2; ESTIMA.TE0.CMANIITYOF 3 WAS TANK FILLED WITH VES f—+ NO ❑ SUBSTANCEAEMAWNG GALLONS' INERT MATERIAL? I_t THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE. IS TRUE AND CORRECT APPLICANT'S NAME f DATE (PRINTED 8 SIGNATURFa"'— � ) !� Ttik ,; ` � � �� v C ; �� . /'f L 1., V r F^ *1...�-� V �� elf /��t., T✓"` °� LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # TANK # STATE I. D.# � � �� / �? ., ��-�� r: PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE �. FORM B (7-9T) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION - FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. i • . I FOR003413-RS