COMPLIANCE INFO_1993-2002 - Laserfiche WebLink

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lop STATE OF CALIFORNIA ('�JI;Y " •r. l� e �ti9 STATE WATER RESOURCES CONTROL BOARD JJJ//t } f UNDERGROUND STORAGE TANK PERMIT APPLICA HE A COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. 9�€ SE VI MARK ONLY FX—] 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMj�jtljj I t W 7 N CL ONE ITEM ❑F—] ED PER IT 2 INTERIM PERMIT ❑ 4 AMENDTEMPORARY TANK CL SURE ❑E] 8 TANK REMOVED O DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ANASTAS 4 S M PM MINI MART I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# UNKNOWN B. MANUFACTURED BY: XERXES C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS:10,0 0 0 II.TANK CONTENTS IF A-1 IS MARKED,CO LETE ITEM C. A. FX-] 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C ❑ 1a REGULAR ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ® 1b PREMIUM ❑ 4 GASAHOL ❑ 7 METHANOL UNLEADED ❑ 5 JET FUEL O ❑ 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 ALL THAT APPLIES IN BOX D AND E A. TYPE OF ® 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN 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 F—] 1 RUBBER LINED F-] 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR LINING F-] 5 GLASS LINING ® 6 UNLINED F-] 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES X 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) 19 9 3 OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) 19 9 3 IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION AM 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL AUl 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 STEEL A U 3 POLYVINYL CHLORIDE(PVC)AnUU 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U s 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 [X 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING 3 INTERSTITIAL 99 OTHER MONITORING V.TANK LEAK DETECTION FF- 1 VISUAL CHECK © 2 INVENTORY RECONCILIATION F--] 3 VADOZE MONITORING F-14 AUTOMATIC TANK GAUGING F—] 5 GROUND WATER MONITORING 6 TANK TESTING ® 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO ❑ 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 (PRINTED a SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW �U COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# 7Z ev f 3 sj PERMITNUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE �J FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. 0 0 FOR003413•R5