COMPLIANCE INFO_1991-2004 - Laserfiche WebLink

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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD D E C 2 2 1992 UNDERGROUND STORAGE TANK PERMIT APPLI "ISM0 W. , AL, HE., C.0 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. PER M R/ ERN I C U MARK ONLY 1 NEW PERMIT F--] 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY ONE ITEM F-] 2 INTERIM PERMIT F-] 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVE DBA OR FACILITY NAME WHERE TANK IS INSTALLED: o IZPD- 1. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.* vrqy-- B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: ILTANKVNTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A. Zl MOTOR VEHICLE FUEL F-] 4 OIL B. C. [::] 1.RELEAGULAR ❑ 3 DIESEL Ej 6 AVIATION GAS UNDED 4 ASAHL 2 PETROLEUM F7 80 EMPTY F-] 1 PRODUCT E::] 1 bUNLEADEPREMIUM GFUELOE]ET 5 J 7 METHANOL D E::] 3 CHEMICAL PRODUCT F-] 95 UNKNOWN E] 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED 011 Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF N?"i DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM F--1 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK F-] 1 BARE STEEL ❑ 2 STAINLESS STEEL �3 FIBERGLASS E] 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE F--] 6 POLYVINYL CHLORIDE 7 7 ALUMINUM E:] 8 100°/. METHANOL COMPATIBLEW/FRP (Primary Tank) ❑ 9 BRONZE D 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED F-] 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR F-] 5 GLASS LINING ❑ 6 UNLINED F-1 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES NO D.CORROSION F-1 1 POLYETHYLENE WRAP F-] 2 COATING F7 3 VINYL WRAP �4 FIBERGLASS REINFORCED PLASTIC PROTECTION F-] 5 CATHODIC PROTECTION F-] 91 NONE F795 UNKNOWN F-] 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) j0z'- 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 I SUCTION A&P 2 PRESSURE A U 3 GRAVITY 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 A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A C)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 f?"16 AUTOMATIC LINE LEAK DETECTOR l-LINE TIGHTNESS TESTING 1,N,(T,E,RS(,TR'TI INA,�L D 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK [:Z2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING d7 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 UNDE ENALTY OF PE URY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME DATE !:mg (PRINTED&SIGNATURE) 4— 7—, ICl — LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE F9d'R NUMBERS BEL2! - ill-, ? COUNTY# JURISDICTION# FACILITY# TANK# STATE 04 JVD-- 7CJ U PERMIT NUMBER PERM TE A IT EXPIRATION DATE (PPROVED BY/DA a 4D - I FORM 8 (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•-?0R*I*VQrESS A CURRENT FORM A HAS BEEN FILED. FOR00348-R5