COMPLIANCE INFO_FILE 11 - Laserfiche WebLink

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F � STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD ; _. 0 UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B 1 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT lJ 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. OWNER'S TANK 1. D. 0 879-G3U1 B. MANUFACTURED BY: TRUSCO C. DATE INSTALLED(MO/OAYNEAR) 6/3/94 D. TANK CAPACITY IN GALLONS: 15,000 II. TANK CONTENTS IF A -i IS MARKED. COMPLETE ITEM C. A. Q 1 MOTOR VEHICLE FUEL ❑ 4 OIL ® 2 PETROLEUM a 80 EMPTY ® 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 8. ❑X 1 PRODUCT ❑ 2 W C. LAJ to REGULAR UNLEADED R 3 DIESEL ❑ 6 AVIATION GAS lb PREMIUM UNLEADED L�Ji 4 GASAHOL n 7 METHANOL to MOGRADE UNLEADED 5 JET FUEL IL�Jj 8 M85 ❑ 2 LEADED 99 OTHER (DESCRIBE IN REM D. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. 9: 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 ® i DOUBLE WALL ❑ 3 SINGLE WAIL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 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 (PNM'TY Ta n4 ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ® 99 OTHER C. INTERIOR 0 1 RUBBER LINED ❑ 2 ALKYO LINING ❑ 3 EPDXY LINING ® 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ® 6 UNLINED ❑ 95 UNKNOWN 99 OTHER COATING IS LINING MATERIA. COMPATIBLE WITH 100°6 METHANOL? YES _ NO_ N/A D. EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 0 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ® 95 UNKNOWN ❑ 99 OTHER E. SPILL AND OVERFILL, BIC SPILL CONTAINMENT INSTALLED (YEAR) �j ca" OVERFILL PREVENTION EOUIPMENT INSTALLED (YEAR) ygg_e} _ DROP TUBE YES �`,�� NO STRIKER PLATE YES � NO DISPENSER CONTAINMENT YES NO IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND. BOTH IF APPLICABLE *90% Audible/Visual Alarm A. SYSTEM TYPE A U 1 SUCTION U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING 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 CORROSION PROTECTION A U A U A U 1 BARE STEEL S 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 (PVCA U 4 FIBERGLASS PIPE 7STEELWICOATING A U 8 100% METHANOL COMPATIBLEW/FRP A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ® 1 —c- LINE LEAK ❑ DETECTOR N11TEROTIAL ❑ 4 ELECIROMC LINE a 2 UNE T09WESS ® 3 WM1WS N TESTING MOMTORNG LEAK DETECTOR 5 AUTOMATIC PUMP ED 99 OTHER SHVTDOWN V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL INVENRECONCILIATION ❑ 3 MONITORING VADOZE®4 GAUGING AUTOMATIC TANK [—]S GROUNDWATER ❑ 6 TANK TESTING ® 7 CONTINUING INTERSTITIAL ❑ 8 SIR ❑ 9 TRK GAUD MANUAL ❑ 10 �SNnTNHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI. TANK CLOSURE INFORMATION (PERMANENT CLOSURE N -PLACE) 1. ESTIMATED DATE LAST USED (MO/DAYNS) 2. ESTIMATED OUANTITY 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 TANK OWNER'S NAME DATE / G (PRINTED B SIGNATURE) C. Susi Jackson _ 12( LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF tHe FOUR NUMBERS BELOW COUNTY N JURISDICTION 9 FACILITY /t TANK It STATE I.D.4 m = I I I T7-F� 17= PERMIT NUMBER PERMIT APPROVED BY/DATE 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. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (6-95) FOR0034"7