COMPLIANCE INFO_1993-2002 - Laserfiche WebLink

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#x � �P ° STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD �1S�r';�.n u _ UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B � '�, xas o COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. I MARK ONLY ❑J 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 ❑ 8 TANK REMOVED DBAOR FACILITY NAME WHERE TANK IS INSTALLED: kkk 1. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK;L b.u t; s/ B. MANUFACTURED BY: F" k.)Alt --------- , C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: r ILTANKCONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. Ig, A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C ❑ 1a REGULAR ❑ 3 DIESEL ❑ 6 AVIATION GAS UNLEADED ❑ 4 GASAHOL Y ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUG� ❑ 1bUN EAIDED ❑ 5 JET FUEL ❑ 7 METHANOL ' ❑ 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.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALLTHAT APPLIES IN BOX D AND E I A. TYPE OF 171 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN 3 SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER 1 BARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC "f B. TANK ` 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 ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR.� ❑.,5 GLASS LINING '� 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER ,.: LINING k,. IS LINING MATERIAL COMPATIBLE WITH 100./ METHANOL? YES_ NO D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC a PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN ❑ 99 OTHER I . 49 ,4" E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR)IV.PIPING PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A 2 PRESSURE A U 3, GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEER; A U 3 PQLYVINYL CHLORIDE(PVC)A4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W./FRP PROTECTION A 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 ❑ 99 OTHER 2 LINE TIGHTNESS TESTING 3 INTERSTITIAL § MONITORING ❑ V.TANK LEAK DETECTION ❑ ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING 1 VIS�IAL CHECK ❑ 6 TANK-TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER M I VI.TANK CLOSURE INFORMATION j 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO ❑ 33i SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE y (PRINTED B SIGNATURE) a LOCAL AGENCY USE ONLY THE STATE LD NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW a , COUNTY# JURISDICTION# FACILITY# TANK# f STATE I.D.#/ t 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 I FORM B (12-91) FOR 00348-R6 Vis;