COMPLIANCE INFO_1995-1999 - Laserfiche WebLink

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2. „�• :' STATE OF CALIFORNIA .-' , -,• $TATE WATER RESOURCES CONTROL BOARD ►`- UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B Y� �LIRDN q�R COMPLETE A SEPARATE FORM AM'EAptI; ANK SYSTEM. MARK ONLY 1!NEW PERMIT F7 3 RENEWAL PERMIT 5 CHANE OF INFORMATION 7 PERMANENTLY CL08ON ITE ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 8 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN j A. OWNER'S TANK I.D.# )k' ANUFACTURED BY: i ' C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: I f C If.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A. [ -1 MOTOR VEHICLE FUEL 4 OIL 1a REGULAR 3 DIESEL ❑ B. C• ❑ UNLEADED ❑ ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY PRODUCT ❑ 1b PREMIUM ❑ 4 GASAHOI ❑ 7 METHANOL UNLEADED ❑ 5 JET FUEL ❑ 3 CHEMICAL PRODUCT a 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) I D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED � C.A.S. 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 q SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER { B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100°/ METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER !x ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING !! C.IN IN NIGR F-] 5 GLASS LINING F--] 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO D.CORROSION e F—] 1 POLYETHYLENE WRAP F—] 2 COATING ❑ 3 VINYL WRAP ❑'4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑06 UNKNOWN E:] 99 OTHER .k ` - E SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) _ IV. hIAIGINFORMATIDN CIRCLE A IFABOVE G NDOR U IF UNDERGROUND,BOTH IF APPLICABLE ? YSTEM TYPE A U 1 SUCTION p PRESSURE A U 3 GRAVITY A U 99 OTHER r B. CONSTRUCTIQN A U 1 SINGLE WALL A DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER , ` C. MATERIAL AND A U BARE STEEL A U 2,STAINLESS STEEL A U 3 POLYVINYL,CHLORIDE(PVC)A,U 4 FIBERGLASS PIPE CORROSION A 0. 6 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP ='E PROTECTION p U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING 3 IMONITORN E STI ING G 99 OTHER k ❑ ❑ ❑ ❑ '. V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK F--] 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORBM 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION F�T IMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO SUBSTANCE REMAINING GALLONS INERT MATERIAL? 17 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME DATE (PRINTED&SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OFTHE FOUR NUMBERS BELOW At COUNTY# JURISDICTION# FACILITY# TANK# n STATE LD.# ! �❑_' ( 1 1161 ► 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) . FOR0034B-R6 r ; y Y 4`� ar.�-a ..��. _ - "'-;.�:a��A,'-t.::.,.aa�ii.'�r'"'+�•'",..;may �tii�fw€t^+s�..�A.::.�.`iadn,tA�'-u.'A'�s:;-.ma.�.,i,�t�-nr?` "fc>�>',^'"'-'�S'G.��^=`'t�ta"rrxr.1.i"".�'bvR�a'Onto.�t's'�''`'��y`'',.vpE*"P'