COMPLIANCE INFO_1986-2004 - Laserfiche WebLink

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SPURGES STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD 3 _ UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B °4(iFOR N,� COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO SITE ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED A� DBA OR FACILITY NAME WHERE TANK IS INSTALLED:�09� C/ 1. TANK DESCRIPTION COMPLETE ALL ITEMS -- SPECIFY IF UNKNOWN A. OWNER'S TANK I. D. #, B. MANUFACTURED BY: C. DATE INSTALLED (MO/DAY/YEAR) ' D. TANK CAPACITY IN GALLONS: Op IL TANK CONTENTS IFA-11SMARKED.COMPLETEITEM C. A L I1 MOTOR VEHICLE FUEL ❑ 4 OIL g, C ❑ 1a ULAR ❑ 3 DIESEL ❑ 6 AVIATION GAS NLEADED ❑ 2 PETROLEUM 0 80 EMPTY 1 PRODUCT ❑ 4 GASAHOL 1b PREMIUM ❑ 7 METHANOL UNLEADED ❑ 5 JET 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. # : 006`p/ III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A. B. AND C. AND ALL THAT APPLIES IN ROX D AND F A. TYPE OF F-] 1 OUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (V TED TANK) ❑ 99 OTHER B. TANK F-]1 BARE STEEL F-]2 STAINLESS STEEL EF3 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 CONCRETE A U ❑ 1 RUBBER LINED n 2�LKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING 6 UNLINED: 95 U OWN E]99 OTHER - D. LEAK DETECTION IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES NO INTERSTITIAL D0YCTOR E5 2 LINE TIGHTNESS TESTING ❑ 3 D. CORROSION ❑1 POLYETHYLENE WRAP F-]2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION�4 ATHODIC PROTECTION ❑ 91 NONE�j❑ 95 UNKNOWN ❑ 99 OTHER E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) / 9/0 OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) IV. PIPING INFORMATION CIRCLE A IF ABOVE GRQJdNpOR U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION APRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC)AFIBERGLASS PIPE CORROSION A U 5 A MINUM A U CONCRETE A U 7 STEEL W/COATING AV_ 100°/ METHANOL COMPATIBLE W/FRP PROTECTION A U GALVANIZED STEEL A I I 0 CATHODI ROTECTION - A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 AUTOMATIC LINE LEAK INTERSTITIAL D0YCTOR E5 2 LINE TIGHTNESS TESTING ❑ 3 ❑ 99 OTHER MONITORING V. TANK LEA -DETECTION F4�1< AL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING ❑ 5 UND WATER MONITORING TESTING ❑ T INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN 99 THER VI. TANK CLOSURE INFORMATION 1. ESTIMATED DATE LAST USED (MO/DAY/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS F HAS BE N COMPLETED UNDER PENFPERJURY, AND TO THE EST OF MY KNOWLEDGE, IS TRUE AND CORRECT ANTS N E a DATJ I SIGN Ud A IIIIVA LOCAL AG EN Y USE ONLY THE STATE I.D. NUMBER IS 90P SED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # TANK # STATE I. D.# d PERMIT NUMBER P MIT PR ED BY/DAT f PERMIT EXPIRATION DATE FORM B (7-91) THIS FORM MUST Bg ACCOMPANIED BY A PERMIT APPLICA ON . FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. FOR00348-RS