COMPLIANCE INFO_FILE 11 - Laserfiche WebLink

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P y " tb .w -CS i STATE OF CALIFORNIA = °o STATE WATER RESOURCES CONTROL BOARD ; + 0 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 ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Lawrence Livermore National Laboratory Site 300 1. TANK DESCRIPTION COMPLETE ALL ITEMS - SPECIFY IF UNKNOWN A. OWNERS TANK L D. a 882-DlUl B. MANUFACTURED BY:MOdern Welding CO. , Inc. C. DATE INSTALLED (MO/DAY/YEAR) 1988 D. TANK CAPACITY IN GALLONS: 1500 IL TANK CONTENTS IF A-1 IS MARKED. COMPLETE ITEM C. A� ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL ® 2 PETROLEUM ® 60 EMPTY ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN e. ® 1 PRODUCT 2 WASTE C. la REGULAR UNLEADED a 3 DIESEL ❑ 6 AVIATION GAS ib PREMIUM UNLEADED Q 4 GASAHOL❑ 7 METHANOL to MOGRADE UNLEADED 5 JET FUEL ❑ 8 M85 ❑ 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.1) IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED Diesel C. A. S. #: N/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 02 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR UNER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK CD 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 (P6M" Tack) Q 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ® 99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ® 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES _ NO_ N/A D. EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ® 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER Steel Clad with FRP E. SPILL AND OVERFILL etc. SPILL CONTAINMENT INSTALLED (YEAR) -1,QAR OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) + DROP TUBE YES NO STRIKER PLATE YES NO DISPENSER CONTAINMENT YES NO IV. PIPING INFORMATION /A CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND. BOTH IF APPLICABLE * Positive shut -of f valve in drop tube A. SYSTEM TYPE A U i Sumo) A U 2 PRESSURE &U) 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A& 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND CORROSION PROTECTION A U A U A U 1 BARE STEEL 5 ALUMINUM 9 GALVANIZED STEEL A U 2 STAINLESS STEEL A U A U 6 CONCRETE A U A U 10 CATHODIC PROTECTION 3 POLYVINYL CHLORIDE (PVC) A I) 4 FIBERGLASS PIPE 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ I MEO CAL LME LEAK ❑2 UNE TO(T ESS ® 3 COPMM s MTEMMK [:]4 ELECTRO14C UNE ❑ 5 AUTOMATIC RW ED 99 OTHER TESTMG tOMTCRMG LEAK DETECTOR SHUTDDwN V. TANK LEAK DETECTION ❑ i VISUAL CHECK ❑ 2 MANUAL INVENTORYRECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 GAUGING C TANK ❑ S GROUND MONITORINGWATER ❑ 6 ANNUALTESTING ® 7 CONTINUOUS INTERSTITIAL ❑ 8 SIR ❑ 9 TANK LY MANUALGING ❑ 10 MONTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHERTESTING VI. TANK CLOSURE INFORMATION (PERMANENT CLOSURE IN-PLACE) I. ESTIMATED DATE LAST USED (MO/DAY/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YESNO SUBSTANCE REMAINING GALLONS I IINERT MATERIAL ? ❑ ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY. AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME DATE ` fp (PRINTED i SIGNATURE) C. Susi Jackson LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # TANK If STATE I.D.4 C❑ = I I I I I I 1 (777 - PERMIT NUMBER I PERMIT APPROVED BY/DATE I PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION . FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLAN. RLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM 8 (6-95) FOR00348•R7