COMPLIANCE INFO_1985-1998 - Laserfiche WebLink

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STATE CF CALIFORNIA . STATE WATER RESOURCES CONTROL BOARD '`tti ."• ry'' UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B W wsa a ft s. COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. '`'• �'1' MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT j5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE (❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 3d• tt � ,✓� I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.x �_ B. MANUFACTURED BY.- C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: biat II.TANK CONTENTS IF A•1 IS MARKED,COMPLETE ITEM C. A. [;�" 1a REGULAR1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. UNLEADED � 3 DIESEL � � 6 AVIATION GAS F72 PETROLEUM F7 So EMPTY PrCDUCT ib PaEmIUM 4 GASAHOL I 7 METHANOL UNLEADED 5 .;ET 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.o III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALLTHAT APPL'E_ V BOX 0 AND E A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER 95 LNKNCWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT VAULTED-ANK) '799 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS i_J 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ALUMIN;.m -78 '=w. VE»ANOL COMPATIBI f:W;FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL Y95 UNKNCNN ❑ 99 1 RUBBER LINED ❑ 2 ALKYD LINING Z95 99 co-,E;EPDXY ::KING ❑ 4 P-ENC-C LINING LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED UNKNCNN � _ IS LINING MATERIAL COMPATIBLE WITH 100.METHANOL? YES_ NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 INYL WRAP ❑ 4 F'3ERGJSS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ UNKNOWN (❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT VSTALLED(YEAR)_ l IV.PIPING INFORMATION CIRCLE A IFABOVE GROUND OR U IF UNDERGROUND,30TH IF APPLICABLE A. SYSTEM TYPE A U i SUCTION 2 PRESSURE A U 3 GRAVITY A U 99 C7 tER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH &fV 95 UNsMWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYV;NYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL.W COATING A U S 1009 METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION AAU)95 UNKNOWN A U 99 OTHER D. LEAK DETECTION I❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ I'NT G i 99 OTHER V.TANK LEAK DETECTION 1 VISUAL CHECK `TK INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGNG❑ 5 GROUND WATER MONITORING 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑I 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/OAY/YR) 2.ESTIMATED OUANTITY OF 3.WAS TANK=1LLED WITH SUBSTANCE REMAINING GALLONS INE3T VATERIAL? YES ❑ P1O❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOW I—SCIGE, IS TRUE AND CORRECT APPLICANTS NAME (PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE LD.# ml ❑�� I PERMIT NUMBER I PERMIT APPROVEDBY/DATE ± PERMIT EXP,RA-C`JNDATE FORM B (7.91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATiCN•FORM A,UNLESS A CURRENT FORM A HAS/r Ev FORM845