COMPLIANCE INFO_1995-1999 - Laserfiche WebLink

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�Sou- eg STATE OF CALIFORNIA r P . c't STATE WATER RESOURCES CONTROL BOARD 3 UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B ate : COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED J(f�a DBA OR FACILITY NAME WHERE TANK IS INSTALLED: O V( `/ �►f/��' .. t/M� I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK 1.D.# B. MANUFACTURED BY: D w Yl C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: 000 S II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1.REGUUNLEAAR ❑ 3 DIESEL 6 AVIATION GAS �� 2 PETROLEUM F-1 80 EMPTY PRODUCT �b PREMIUM ❑ 4 GASAHOL ❑ 7 METHANOL F--] 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 LEADED 2 WASTE ❑ UNLEADED ❑ 9J 9 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.x 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 EZ�2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK 1 BARE STEEL 2 STAINLESS STEEL F-] 3 FIBERGLASS [1] 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER 1 RUBBER LINED ❑ 2 ALKYD LINING V95 PDXY LINING F-] 4 PHENOLIC LINING LINING C.INTERIOR F-] 5 GLASS LINING ❑ 6 UNLINED 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 F-] 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) W OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) lvl7 IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 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 W1 COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 5 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 � MONITORING gg OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING F-] 5 GROUND WATER MONITORING a 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE �95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION mw STIMAT D ATE LAT ED(MO/DA R� 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES NO mwL.� SUBSTANCE REMAINING GALLONS INERTMATERIAL? T IS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THfIBEST O K O GE, IS TRUE AND CORRECT APPLICANTS NAME ` t DATE (PRINTED&SIGNAT R - N ,s LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FO NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# ❑ E l I I PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED, FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (12-91) 0 0 /4� FOR0034B-R6