COMPLIANCE INFO_1986-1995 - Laserfiche WebLink

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a 'yOuw ! C STATE OFCAUFORNIA w t STATE WATER_RESOURCES.CONTROL BOARD a o UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 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 6 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: me- 5ZMna I, 3-e4 I =, j ,: PO J I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.a 3 B. MANUFACTURED BY: r�N C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLOONS: 7,ryi 7 II.TANKCONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. 1 MOTOR VEHICLE FUEL ❑ 4 OIL8. C. V 1aREGULAR UNLEADED ❑ 3 DIESEL ❑ g AVIATION GAS A ❑ 2 PETROLEUM ❑ 80 EMPTY i PRODUCT ❑ 1b PREMIUM 4 GASAHOL ❑ 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.a: 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 (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL PUI 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING F--] 4 PHENOLIC LINING C.INTERIOR F-15 GLASS LINING ❑ 6 UNLINED F%Z 95 UNKNOWN ❑ 99 OTHER LINING `.N IS LINING MATERIAL COMPATIBLE WITH 100°% METHANOL? YES_ 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) 9A9 Amj OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR)UN A IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IFUNDERGROUND,BOTH IFAPPLICABLE A. SYSTEM TYPE A U i SUCTION Aa?2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A jp95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 7 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 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 ^lam[ 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ i AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 INTERSTITIAL MONITORING 99 OTHER U/114t116/ V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ® 95 UNKNOWN ❑ 99 OTHER Vl.TANK CLOSURE INFORMATION 1,E TWATED DAV LAST USED( O/DAY/YR 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES NO E::]x e SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 UeN THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME (PRI D 8 NATURE) C DATE Qe A'—Ir, (� LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# m Em = PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIERY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH T4WAI AGENCY IMPLEMENTING THE UNDERGROUND ST TANK REGULATIONS FORM B (12.97) FOR00348•R6