COMPLIANCE INFO_1993-1994 - Laserfiche WebLink

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My U • STATE OF CALIFORNIA �� ti. STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B rn , ,� ' , 0 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM C/`spa ^"I" MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: �Y V-V I. TANK DESCRIPTION COMPLETq ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.11 B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) t D. TANK CAPACITY IN GALLONS: J�s� nCp�(�r�d 4- OtZ- r j ILTANKCONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. -v -6 t. 000 Q/ A. F-] 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. 1a REGULAR Ej 3 DIESEL ❑ UNLEADED ❑ 6 AVIATION GAS 2 PETROLEUM 0 80 EMPTY ❑ 1 PRODUCT ❑ lb PREMIUM ❑ 4 GASAHOL ❑ 7 METHANOL F-] 3 CHEMICAL PRODUCT 0 2 LEADED 95 UNKNOWN 2 WASTE UNLEADED a 5 JET FUEL ❑ ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.A 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 0 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ® 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK jg�1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS I E E F CED PLASTIC MATERIAL F-] 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM NtMANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER F-] 1 RUBBER LINED F-] 2 ALKYD LINING ❑ 3 EPDXY LINING [-] 4 PHENOLIC LINING C.INTERIOR LINING ❑ 6 5 GLASS LINING C UNLINED ❑ 95 UNKNOWN E] 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION [j4•-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 GROUND OR U IF UNDERGROUND OTHIFAPPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A GRAVITY A U 99 OTHER B. CONSTRUCTION A 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A 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 D 1 AUTOMATIC LINE LEAK DETECTOR ZF2 LINE TIGHTNESS TESTING 3IAL MONITORING ❑ 99 OTHER V.TANK LEAK DETECTION VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING u 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION Pe 1.ESTIMATED DATE LAST SED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES SUBSTANCE REMAINING (�/ GALLONS INERT MATERIAL? D NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND 90RRECT APPLICANTS NAME DA E (PRINTED 8 SIGNATURE)M1 ` // Z I l '`Ar� LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBMUt; COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# m �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. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (12-91) 0 0 FOR00348-R6