INSTALL 1999 - Laserfiche WebLink

Home Browse Search

From: LARRY SHEPHERD To: STEVE SASSON Date: 7/19199 Time: 4:22:08 PM Page 3 of 3 STATE OFCALITORNIA STATE WATER RESOURCES CONTROL BOARD V �� UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK OILY1 NEW PERMIT F-17 RENEWAL PERMIT ❑ 9 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ON SIM E ONE ITEM 0 2 INTERIM PERMIT ❑ 4 AMENDED PERNIIT ❑ B TEMPORARY TANK CLOSURE ❑ B TANK REMOVED OBA OR FACILITY NAME WHERE TANK IS INSTALLED: —�jQ c� �� j-� I (rte��/ ✓ r�!�/ .N� I. TANK DESCRIPTION COMPLETE ALL ITEMS - SPECIFY IF UNKNOWN A OWNER'S TANK 1. D. f l �) j7 B. MANUFACTURED BY: ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN C. DATE INSTALLED(MO/OAY/YEARI _S D. TANK CAPACITY IN GALLONS: tb PREMIIN UNLEADED ❑ 99 OTHER 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 96 UNKNOWN ❑ 2 WASTE II, TANK CONTENTS IF A•1 IS MARKED, COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL 6. C. is RID" Luim D ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN 3 nFSEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM❑ 80 EMPTY [__ji PgO0l/CT tb PREMIIN UNLEADED ❑ 99 OTHER 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 96 UNKNOWN ❑ 2 WASTE tc IIIIIII)GRADE UN_FADED ❑ 2 LEADED ❑ 4 STEEL CLAD W) FIBERGLASS REINFORCED PLASTIC 5 JET FUEL ❑ 8 M85 99 O1H£R (DESCRIBE IN REL D.6EL.OW) D. IF (k1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. k S. 9: 01, TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A. 8, AND C, AND ALL THAT APPLIES IN BOX 0 AND E A. TYPE OF yCJ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT A4P2 DOUBLE WALL A U ❑ 99 OTHER B. TANK ❑ I BARE STEEL 2 STAINLESS STEEL Le 3 FIBERGLASS ❑ 4 STEEL CLAD W) FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 4 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMIFAIM ❑ 8 10D% METHANOL COMPATI6LE WlFRP Tr iT-1 ❑ 9 BAONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C BRERIDR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR 5 GLASS LINING ❑ 6 UNLINED ❑ 05 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES _ No— Il EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP � 4 FIBEF45LASS REINFORCPD "STIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER SPILL CONTAJNMENT INSTALLED (YEAR) OVERFILL PREVENTLON EQUIPMENT INSTALLED (YEARS I:. SPILL AND OYEAFILL, AGC. DROP TUBE YES 40 STRIKER PLATE YES NO DISPENSER CONTAINMENT YES _ NO IV. PIPING INFORMATION CIFICLE A IF ABOVE GROUND OR U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTM TRIPE A c1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER * CONSTRUCTION A U 1 SPIGLE WALL. A4P2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 9e OTHER C. MATERIA- AND CORROWN PROTECTION A U 1 BARE STEEL A U 5 ALUMINUM +IAIIIlED 9T A U 2 STAINLESS STEEL A U A U 6 CONCRETE A U L A U 10 CATHODIC PROTECTION 3 POLYVINYL CHLORIDE (PVC)A494 FIBEROLASS PIPE T STEEL WI COATING, A U 8 1DD% METHANOL COMPATIBLEWIFRP A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION E LN IHNC 111151 PC. ❑ 2 TI M 86 3 OOI�WCµ p ,MB16Tf1 IL ❑ I ELICT pptfE El gA pOMTI c:]99 oitiRn Y. TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL INANTORYFECONCNJATION O 3 VALDOZE MONITORING ❑ 4 GAUGING C TMA( ❑ 5 GROUNDWATER R ❑ 8 ANNUAL TANk 7 MONI NUCUR140 I�NTEASTMAL ❑ 6 SIR ❑ 9 TANK GAUGING ❑ 10 TMO ESTING TANK [:] 95 UNKNOWN _ ❑ 99 OTHER VL TANK CLOSURE INFORMATION (PERMANENT cLosuRE IN.NX: j I. ESTMMTED DATE LAST USED (MOA)AYNTQ 2. ESTIMATED QUANTITY OF{ 3. WAS TANK FILLED WITH YES ❑ ❑ SUBSTANCE REMAINING—GALLONS I INERiT MATERIAL 7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANIK OWNER'S NAME _! DATE IPRMEO a sHvaAiUi1E1 ��G.bh � `j 7 � �% LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY A JURISDICTION N FACILITY A TANK i C) STATE 1.0 m �j- I F -r -l - M 5 a AERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE — 7� 99 AIQ a W wIcr o& Ai rnYDA Wcn AV A DCO rT ADAI r.AT10N. Fe Am r. VaFSR A CUPWRT FORMA m" 9691 FIIFD. FORM C MUST BE COMPLETED FDI M7ALLATIDNS. THIS FOR SHOULD BE ACCOMPANIED BY A PLOY PLAN. FILE THIS FORM WITH THE LOCAL AGEMCY BIPLELff_WM THE UNDERGROUND STORAGE TANK REGULATIONS FORM 5 (6.93)