COMPLIANCE INFO_1995-2002 - Laserfiche WebLink

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fsause F9 STATE OF CALIFORNIA W ". STATE WATER RESOURCES CONTROL BOARD W v UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B o IN COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED 07 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 1 t-1 47 .7, TANK nFSCRIPTION COMPI FTE ALL ITEMS -- SPECIFY IF UNKNOWN 1 A. OWNER'S TANK 1. D. #® B. MANUFACTURED BY: C. DATE INSTALLED (MO/DAY/YEAR) I c� '� ' D. TANK CAPACITY IN GALLONS: II TANI(CONTFNTS ICA.tI3MARKFnCnMPIPTFITFMC- A ❑ 1 MOTOR VEHICLE FUEL E:]4 OIL e. REGULAR C. ❑ 1aUNLEADED ❑ 3 DIESEL ❑ 6 AVIATIONGAS ASAHOL ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT ❑ 1bUNLEADED 7 METHANOL F—]5 GET FUEL ❑ ❑ 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. #: 111 TANK rnNCTPI IrTION L.IAVIc nNC ITcu nNl v IN RnvFC A R ANn r` ANn Al I THAT APPI IFS IN RnX n ANn F A. TYPE OF 1 DOUBLE WALL �. ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER A U 1'� I 1 BARE STEEL ❑ 2 STAINLESS STEEL F—]3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL "l ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) O 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 ❑ 1 RUBBER LINED ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR F—] 5 GLASS LINING �2 6 UNLINED ❑ 95 UNKNOWN L]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 95 UNKNOWN ❑ 99 OTHER E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) IV. PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE AWI 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 AU 10 CATHODIC PROTECTION 3 POLYVINYL CHLORIDE (PVC) A U 7 STE W/COATING A U p CUUNKNOWN A U 4 FIBERGLASS PIPE 8 100% METHANOL COMPATIBLE W/FRP 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 INTE MONRORING ❑ ss OTHER V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI. TANK CLOSURE INFORMATION 1. ESTIMATED DATE LAST USED (MO/DAY/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YESNO SUBSTANCE REMAINING GALLONS I 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 A SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # TANK # STATE I.D.# 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 WIT f LOCAL AGENCY IMPLEMENTING THE UNDERGROUND S AGE TANK REGULATIONS FORM B (12-91) /,1/ . �� FOR0034 B -R6