COMPLIANCE INFO_1990-2003 - Laserfiche WebLink

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STATE OF CAL I FO R N$ WATER RESOURCES CONTR OARD Z FORM `B': UNDERGROUND STORAGE TANK PR ,RAM 7 TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. -' MARK ONLY ®1 NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM F-12 INTERIM PERMIT ❑4 AMEND ER IT 6, EMPYIA5 TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: Shell Station 2A L i N°E �� FARM TANK- ❑ NO ' I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY tjq A. OWNERS TANK ID# Unknown B. MANUFACTURED BY: iN i C. YEAR INSTALLED 199f D. TANK CAPACITY IN GALLONS: 12 ,000 II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A."a 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED 3 DIESEL 3 CHEMICAL PRODUCT ❑ 4 OIL 'N)51 PRODUCT ❑4 GASAHOL ❑5 JET FUEL —�ff6 AVIATION GAS A."El5 HAZARDOUS ❑ 80 EMPTY [:]95 UNKNOWN 2 WASTE ❑7 METHANOL GoE I E)1 ,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF tV HAZARDOUS SUBSTANCE STORED&C.A.S.# .. III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D J U L 0 9 1990 A.TYPE OF �I 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN ENVIRONMENTAL H EA LT H SYSTEM ❑ 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEL/IRON ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR F-] 1 RUBBER LINED F-] 2 ALKYD LINING F-13 EPDXY LINING ❑ 4 PHENOLIC LINING I LINING ❑ 5 GLASS LINING x 6 UNLINED ❑95 UNKNOWN r cI ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER 4 D.CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC �I + PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ❑ 95 UNKNOWN ❑99 OTHER -- IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE r A.SYSTEM TYPE A U 1 SUCTION A 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A 004 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER i' V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. 4 P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? [::]YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY I COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# [Kill 1 110 1 IL&L01 Z v l� f dd b CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE �7 CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY, 'i j FORM B(6-29-88) THIS FORM MUST BE ACCOMOWBY A,FACILITY/SITE APPLICATION, FORM `A',UNL RENT FORM`A' HAS BEEN`FILED DATA PROCESSING COPY