COMPLIANCE INFO_1992-2000 - Laserfiche WebLink

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yow t STATE OFCAUFORMA STATE WATER RESOURCES CONTROL BOARD W� , UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM Bow a. . moi . 11 • COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY' „0 4.NEW-PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT E] 6 TEMPORARY TANK CLOSURE F78 TANK REMOV26, DBA OR FACILITY NAME WHERE TANK IS INSTALLED:.Chevron Station # 'L:(.0,11 to I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.O.a B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) t- .. ^ D. TANK CAPACITY IN GALLONS: Zt Q Q ILTANKCONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL 4 OIL g, C., to REGULAR 3 DIESEL ❑ 6 AVIATION GAS UNLEADED 4 GASAHOL 2 PETROLEUM E] 80 EMPTY 1 PRODUCT tb PREMIUM E] 7 METHANOL UNLEADED ❑ 5 JET FUEL ❑ 3 CHEMICAL PRODUCT 95 UNKNOWN E 2 WASTE E:] 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.s: 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 (J 1 DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 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 1 RUBBER LINED ❑ 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING 1 C.INTERIOR ❑ 5 GLASS LINING6 UNLINED 95 UNKNOWN ❑ 99 OTHER LINING ISLININGMATERIAL COMPATIBLE WITH 100% METHANOL 7 YES— NO N, �. a?, 1 PO4YETHYLENE- WRAP F-12 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC D.CORROSIOPROTECTION, ❑;`6,CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN 99 OTHER ^� E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) 6� IV,PIPING INFORMATJOId CIRCLE A.IFABOVEGROUNDORq IF UNDERGROUND,130TH IF APPLICABLE A. SYSTEM TYPE A U I SUCTION kku: 2,PRESSURE A=U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A 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 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A 10094 METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION U'06 UNKNOWN A U 99 OTHER D. LEAK DETECTION "l AUTOMATIC LINE LEAK DETECTOR [:] 2 LINE TIGHTNESS TESTING ❑ 1 AIONRORING ❑ OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING [::] 5 GROUNDWATER MONITORING 6 TANK TESTING 7 INTERSTITIAL MONITORING 91 NONE 95 UNKNOWN E:] 99 OTHER Vi.TANK CLOSURE INFORMATION FSTiMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 73.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 APPLICANTS NAME t /A/ DAT (PRINTED&SIGNATURE) _jr LOCAL AGENCY USE ONLY THE;STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK A STATE I.D.# F Fl — :1= I I I ITTl PERMIT NUMBER PERMIT APPROVED BY/OATE 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 WIT LOCAL AGENCY IMPLEMENTING THE UNDERGROUND JAGE TANK REGULATIONS FORM 9 (12-91) tRRi