REMOVAL 1995 - Laserfiche WebLink

Home Browse Search

'OUR 1, STATE OF CALIFORNIA `°>r STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B �° 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 iij 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Saddle City Chevron - 6241 W. Paddock Place, Lodi I. TANK DESCRIPTION COMPLETE ALL ITEMS — SPECIFY IF UNKNOWN A. OWNER'S TANK I. D. M 4 B. MANUFACTURED BY: ATTOW ----------------------- — --- C. DATE INSTALLED (MO/DAY/YEAR) 1983 D. TANK CAPACITY IN GALLONS: 12 , 000 II. TANK CONTENTS IFA-11SMARKFD-COMPLFTFITFMC A. [&1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. to REGULAR 3 DIESEL ❑ I--]6 AVIATION GAS UNLEA ED ❑ 2 PETROLEUM r7 80 EMPTY 1 PRODUCT 4 GASAHOL ❑ ® 1b PREMIDUM ❑ 7 METHANOL UNLEADED ❑ 5 JET FUEL a 3 CHEMICAL PRODUCT a 95 UNKNOWN a 2 WASTE a 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM 0. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. A III. TANK CONSTRUCTION MARK nNF ITEM rw Y IN RnYCC A D ANIn c ANIn Al I TUAT ADDI ICC IKI 0— n A— A. TYPE OF ❑1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER 1:195 UNKNOWN SYSTEM d2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK Eje 1 BARE STEEL ❑ 2 STAINLESS STEEL F-]3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER F-]1 RUBBER LINED F72 ALKYD LINING ❑ 3 EPDXY LINING F-]4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING 6 UNLINED E-195 UNKNOWN El99 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 IFABOVE GROUND OR U IF UNDFRGROUNn ROTH IF APPI ICARI P A. SYSTEM TYPE A U 1 SUCTION A U 2 E S A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 L 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 TAINL S STE 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 10096 METHANOL COMPATIBLE W/FRP 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 IMNOTNERSTITIAL ITORING ❑ 99 OTHER V. TANK LEAK DETECTION 1 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING F--]4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING �Z 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 SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 YES NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED (PRINTED 8 SIGNATURE) •_-.//,// Michael S. Ramos 7-29-94 LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # TANK # STATE I.D.# m PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORM B (7.91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION - FORM A. UNLESS A CURRENT FORM A HAS BEEN FILED. FOR0034B-R5