COMPLIANCE INFO_1985-1997 - Laserfiche WebLink

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you. es STATE OF CALIFORNIA Ma P STATE WATER RESOURCES CONTROL BOARD F UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B m _ COMPLETE A SEPARATE FORM FOR EAC ANK SYSTEM. v' MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT z115 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED ON SIT ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 0 8 TANK REMOVED 0- 7-2 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ©Q 1 Atz � I. TANK DESCRIPTION COMPLETE ALL ITEMS -- SPECIFY IF UNKNOWN A. OWNER'S TANK I. D. # B. MANUFACTURED BY: C. DATE INSTALLED (MO/DAY/YEAR) G✓N 6L D. TANK CAPACITY IN GALLONS: Q®� I.TANKG NIS IFA -1 IS MARKED, COMPLETE ITEM C. w A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. / C• 1dUNLEADED REGULAR 3 DIESEL ❑ 6 AVIATIONGAS ❑ 2 PETROLEUM ❑ 60 EMPTY 1 PRODUCT ❑ 4 GASAHOL ❑ ib PREMIUM DED ❑ 5 JET FUEL � 7 METHANOL F-13 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. R. AND C. AND ALL THAT APPLIES IN BOX D A. TYPE OF ❑ 1 DOUBLE WALL 0 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEMSINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER A U BARE STEEL F72 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC 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 A U ❑ 1 RUBBER LINED 0 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED a�-UNKNOWN ❑ 99 OTHER LINING 10 CATHODIC.P TION A U9 NKNOWN A U 99 OTHER D. LEAK DETECTION IS LINING MATERIAL COMPATIBLE WITH 100 METHANOL? YES_ NO DETECTOR 2 LINE TIGHTNESS TESTING ❑ 3 IMONNTERSTIRORITIALNG D. CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GRUfft OR U IF UNDERGROUND. BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U` 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 ACU 9 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 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 STEF6COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GAL IZED STEEL A U 10 CATHODIC.P TION A U9 NKNOWN A U 99 OTHER D. LEAK DETECTION AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING ❑ 3 IMONNTERSTIRORITIALNG 99 OTHER F T A AI V 1 C A V r1CT!•/%TIr1\I 1 HIM v- r% UG 1 CV I IV17 ❑ 1VI CHECK 2 INVENTORY RECONCILIATION F-]3 VAPOR MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING TANK TESTING ❑ 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 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 8 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # TANK # O G /O STATE I. DA t3E � III 116-17KW 'ERMITNUMBER PERMIT APPROVED BY/DATE,-, 'Z5 PERMIT EXPIRATION DATE FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION - FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. FOR0034B-R4 i