COMPLIANCE INFO_FILE 10 - Laserfiche WebLink

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• SpURCfS STATE OF CALIFORNIA W�G ' cO STATE WATER RESOURCES CONTROL BOARD a UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B � e id COMPLETE A SEPARATE FORM FOR EA TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PER NENTLY CL ED O TE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE I �/ 8 TA REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: LOA&Lel (j jZ,0 X77 I. TANK DESCRIPTION COMPLETE ALL TEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: 1I.TANK CONTENTS IFA-1-IS MARKED,COMPLETE ITEM C. / A ❑ 1 MOTOR VEHICLE FUEL 4 OILB. A C. ❑ la REGULAR 3 DIESEL ❑ 6 AVIATION GAS UNLEA2 PETROLEUM ❑ 80 EMPTY / 1 PRODUCT ❑ 1b PREMIUM 4 GASAHOL ❑ 7 METHANOL A UNLEADED ❑ 5 JET FUEL F--] 3 CHEMICAL PRODUCT F-195 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 F—] 1 BARE STEEL F—] 2 STAINLESS STEEL F—] 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 1009% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING F--] 3 EPDXY LINING F—] 4 PHENOLIC LINING C.INTERIOR LINING F--] 5 GLASS LINING F--] 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 1009 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) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 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 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 INTERSTITITF MONITORING ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING ❑ 6 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 KlkWLEDGE, IS TRU CORRECT APPLICANTS NAME DATE (PRINTED d SIGNATURE) f LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE OUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# 00161611 PERMIT NUMBER PERMIT APPBQVEDBY/DAFE PERMIT EXPIRATION DATE Jo/ -11 FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNL ENT FORMA HAS BEEN FILED. FOR0034645