COMPLIANCE INFO_FILE 11 - Laserfiche WebLink

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-Alk 0 45 00 ".. --k' STATE OF CAUFORNIAY • STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANKPERMIT APPLICATION - FORM B " �� V� COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 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 1. D. 6 871-DlU2 I B. MANUFACTURED BY: Modern Welding CO. , Inc. C. DATE INSTALLED(MOMAY/YEAR) 9/29/94 t D. TANK CAPACITY IN GALLONS: 1000 11. TANK CONTENTS IF A•1 IS MARKED, COMPLETE ITEM C. A ❑ / MOTOR VEHICLE FUEL ®2 PETROLEUM Q 3 CHEMICAL PRODUCT ❑ 4 OIL ❑ 80 EMPTY 95 UNKNOWN e, ❑ 1 PRODUCT ❑ 2 WAST C. 1a REGULAR UNLEADED 1b PREMIUM UNLEADED Ic MIDGRADE UNLEADED ❑ 2 LEADED a 3 DIESEL [D6 AVIATION GAS Q 4 GASAHOLn 7 METHANOL 5 JET FUEL LR 8 M85 99 OTHER (DESCRIBE IN REM D. saom D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED Diesel ❑ 99 OTHER C. A S. 4: N/A 111. 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 ❑ 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 (Primary Tank) ❑ 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°,6 METHANOL? YES _ NO_ N/A D. EXTERIOR 0 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP F-1 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 9/ NONE ❑ 95 UNKNOWN ® 99 OTHER Step 1 Clad With FRP E. SPILL AND OVERFILL, etc. SPILL CONTAINMENT INSTALLED (YEAR) 1994 OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) 1 QQA * DROP TUBE YES --X_ NO STRIKER PLATE YES X 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 U 1 SUCTION A U 2 PRESSURE AU 3 GRAVITY U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION @ U 1 SINGLE WALL A 0 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 A U 2 STAINLESS STEEL A U 5 ALUMINUM A U 6 CONCRETE A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION 3 POLYVINYL CHLORIDE (PVC)A U 4 FIBERGLASS PIPE 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP A U 95 UNKNOWN U 99 OTHER Pl axi hl p pl act i c- D. LEAK DETECTION 1 MEGUlKCAL tai LEAK DETECTOR a 2 UNE tK;HTaEss ®3 C014TiM10US wTERstiml 4 FiECraaeae u O TESTING MONTORNG LEAK ETECMA ❑ 5 AUTOMATIC ED 99 OTHER S"imom V. TANK LEAK DETECTION ANNUAL Q 1 VISUAL CHECK 1:12 RECONCILIATION ❑ MANUAL INVEN3 MONITORING VADOZE®4 GAUGING C TANK ❑ 5 GMONITORINGAUTOMATIROUND WATER ❑ 6 TESTINGTANK 0 7 MONITORING INTERSTITIAL 1:1 8 SIR ❑ 9 WE K GAUD NGAL ❑ 10 MONTTESTIHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER V1. TANK CLOSURE INFORMATION (PERMANENT CLosum 1N -PLACE) 1. ESTIMATED DATE LAST USED (MO/DAYNR) 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` z 1 (PRINM a SKINATURE) C. Susi Jackson LOCAL AGENCY AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY M JURISDICTION # FACILITY N TANK It STATE I.D.4 m F= I I I I I I 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 FORMS (6.95) FOR00348•R7 VA