COMPLIANCE INFO_1991-2004 - Laserfiche WebLink

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$4 . STATE OF CALIFORNIA " STATE WATER RESOURCES CONTROL BOARD W e 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 a 6 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED:Chevron Station # 2O 1378 I. TANK DESCRIPTION COMPLETE ALL ITEMS SPECIFY IF UNKNOWN A. OWNER'S TANK 1.0.t 2 B. MANUFACTURED BY: � K.e S C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: t 0 ILTANKCONTENTS IF A•1 IS MARKED.COMPLETE ITEM C. A I MOTOR VEHICLE FUEL ❑ 4 OIL 7c[--Vl C'• ❑ la REGULAR 3 DIESEL ❑ 6_AVIATION GAS E7] 2'PETROLEUM ❑ 80 EMPTY1 PRODUCT ❑ 1b PREMIUM 4 GASAHOL ❑ 7 METHANOL UNLEADED 5 JET FUEL 3 CHEMICAL PRODUCT E] 95 UNKNOWN2 WASTE ❑ 2 LEADED ff�qq OTHER(DESCRIBE IN ITEM D. BELOW) D. IF(A.t)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED L] t o S.III:- Ill. :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 S. TANK ❑ 1 BARE STEEL E:] 2 STAINLESS STEEL 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 ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO D.CORROSION L❑ 1 POLYETHYLENE'WRAP ❑ 2 COATING ❑ 3 VINYL WRAP '&�' ERGLASS 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 GROUNQ,OR U IF UNDERGROUNQ 90TH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U PRESSURE A U 3 GRAVITY - A U 99 OTHER B. CONSTRUCTION A U t SINGLE WALL A O 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 4_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 �R^3 MONRORING ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING 6 TANK TESTING X7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAYIYR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DAT (PRINTED 8 SIGNATURE) 0r r I p. LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSEDOF Tug FOUL NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# ❑ ��-TT 1 PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH CAL AGENCY IMPLEMENTING THE UNDERGROUNDS E TANK REGULATIONS FORM B (12-91) 1bAf4Wfy .# s