COMPLIANCE INFO_FILE 10 - Laserfiche WebLink

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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD a ,e, k UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B COMPLETE A SEPARATE FORM FOR EA H TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT Pr6 CHANGE OF INFORMATION 7 PERMAN TLV CL ITE ONE ITEM F—] 2 INTERIM PERMIT F—] 4 AMENDED PERMIT TEMPORARY TANK CLOSURE -KZ 8 TANK R OVED O DBA OR FACILITY NAME WHERE TANK IS INSTALLED: jq I. TANK DESCRIPTION COMPLETE ALL ITEMS.- SPECIFY IF UNKNOWN & 300 A. OWNER'S TANK I.D.X L / B. MANUFACTURED BY: l C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: h ILTANKC TENTS IFA-1 IS MARKED,COMPLETE ITEM C. V A. 1 MOTOR VEHICLE FUEL 4 OIL B. C. ix D 3 DIESEL 6 AVIATION GAS 4 GASAHOL • � 2 PETROLEUM � 80 EMPTY ❑ 1 PRODUCT � 7 METHANOL D ❑ 5 JET FUEL 3 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE gg OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.x 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 ❑ DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN SYSTEM SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER B. TANK 1 BARE STEEL F-12 STAINLESS STEEL F-] 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 ❑ 95 UNKNOWN 99 OTHER 1 RUBBER LINED 2 ALKYD LINING F-] 3 EPDXY LINING 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING 6 UNLINED 4KNOWN 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING 3 L WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE t . SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER art B. CONSTRUCTION A U 1 SINGLE WALL A 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 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 A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 MONITORING ❑ 99 OTHER V TANK LEAK DETECTION o1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING E::] 5 GROUND WATER MONITORING F-1 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 SUBSTANCE REMAINING GALLONS NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME (PRINTED&SIGNATURE) DATE +r V, LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF76 FOUR NUMBERS BELOW l COUNTY# JURISDICTIO # k FACILITY# TANK# STATE I.D.A'7 v PERMIT NUMBER PERMIT APPROVED BY/D TE PERMIT EXPIRATION DATE ' THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A FILED. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS + �(ll�} FORM B (12-91) � � l 1 FOR00308-R6