COMPLIANCE INFO_1985-1998 - Laserfiche WebLink

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`8TATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION FORM B I x COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SIP ONE ITEM F7 -2 INTERIM PERMIT n 4 AMENDED PERMIT n 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED~ ILL i DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 'r = -7,#— I. TANK DESCRIPTION COMPLETE ALL ITEMS -- SPECIFY IF UNKNOWN # A. OWNER'S TANK I. D. B. MANUFACTURED BY: AA C. DATE INSTALLED (MO/DAY/YEAR) D. TANK CAf?�1CITY IN GALL LIONS: Z moot/ V ILTANKCONTENTS IFA -1 IS MARKED. COMPLETE ITEM C. 1 MOTOR FUEL A' ❑ 4 OIL 3 C ❑ 1a REGULAR - 3 DIESEL ❑ 6 AVIATIONGAS 1 :y ❑ 80 EMPTY 1 PRODUCT F q GASAHOL GASAHJET ❑ 7 METHANOL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC UNLEADE�!❑ ❑ 5 L 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN .n y;d„ ' 4+prrN oa y. ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SIP ONE ITEM F7 -2 INTERIM PERMIT n 4 AMENDED PERMIT n 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED~ ILL i DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 'r = -7,#— I. TANK DESCRIPTION COMPLETE ALL ITEMS -- SPECIFY IF UNKNOWN # A. OWNER'S TANK I. D. B. MANUFACTURED BY: AA C. DATE INSTALLED (MO/DAY/YEAR) D. TANK CAf?�1CITY IN GALL LIONS: Z moot/ V ILTANKCONTENTS IFA -1 IS MARKED. COMPLETE ITEM C. 1 MOTOR FUEL A' ❑ 4 OIL g,. C ❑ 1a REGULAR ILTANKCONTENTS IFA -1 IS MARKED. COMPLETE ITEM C. 1 MOTOR FUEL A' ❑ 4 OIL g,. C ❑ 1a REGULAR - 3 DIESEL ❑ 6 AVIATIONGAS 4/2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT UNLEADED ❑ 1b PREMIUM q GASAHOL GASAHJET ❑ 7 METHANOL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC UNLEADE�!❑ ❑ 5 L 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 ❑ 95 UNKNOWN=, 99 ❑ 99 OTHER C. A. S. #: 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 1 DOUBLE WALL 0 3 SINGLE WALL WITH EXTERIOR LINER 0 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 ❑ 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 - IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES NO D. CORROSION 0 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION 0 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN 0 99 OTHER } E: SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) 1 OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) .1V. PIPING INFORMATION IV CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND. 80TH IF APPLICARI F A: SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION V' 1 SINGLE WALL A(p2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99OTHER C. MATERIAL AND CORROSION PROTECTION A U 1 BARE STEEL A U 5 ALUMINUM A U 9 GALVANIZED STEEL A U A U A U 2 STAINLESS STEEL A U 6 CONCRETE A U 10 CATHODIC PROTECTION 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP A U 95 UNKNOWN A V 99 OTHER�bf-,- D. LEAK DETECTION INTERSTITIAL ❑ 1 AUTOMATIC LINE LEAK DETECTOR >1 2 LINE TIGHTNESS TESTING ❑ 3 MONITORING ❑ 99 OTHER V. TANK LEAK DETECTION 0 1 VISUAL CHECK K2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING N4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING 6 TANK TESTING F>< 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI. TANK CLOSURE INFORMATION 1. ESTIMATED DATE LAST USED (MO/DAY/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL ? YES ❑ NO ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE 4EST OF Y KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME yyy DATE (PRINTED 8 SIGNATURE) s t M# LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW Pf COUNTY # JURISDICTION # _FACILITY# TANK # STATE I.D.# T '� PERMIT NUMBER ER PMIT APPROVED BY/DATE PER MIT .I - 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 FORM B (12-91) . _ FOR00346-R6 720