COMPLIANCE INFO_1986-1996 - Laserfiche WebLink

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OUR Ey C • STATE OF CALIFORNIA ° s STATE WATER RESOURCES CONTROL BOARD 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 CLOS ONE ITEM ❑ 2 INTERIM PERMIT F--] 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED r mwrl- DBA OR FACILITY NAME WHERE TANK IS INSTALLED: A124-0 P40. o548 ,e, I. TANK DESCRIPTION COMPLETE ALL ITEMS - SPECIFY IF UNKNOWN A. OWNER'S TANK I. D. # , �; V �L B. MANUFACTURED BY: C. DATE INSTALLED (MO/DAY/YEAR) O S / (� D. TANK CAPACITY IN GALLONS: 400 o II.TANKCONTENTS IFA -1 IS MARKED. COMPLETE ITEM C. A. L� ' MOTOR VEHICLE FUEL ❑ 4 OIL B. C. �aUNLEADED ❑ REGULAR 3 DIESEL 6 AVIATION GAS F-]2 PETROLEUM ❑ 80 EMPTY [?'I PRODUCT ❑ 1b PREMIUM ❑ 4 GASAHOL O 7 METHANOL UNLEADED JETL 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE a 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D: IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. # III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A. R. AND C. AND ALL THAT APPLIES IN BOX D AND F A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM [2 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK 12 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 (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN a 99 OTHER 7 STEEL W/ COATING ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING E�r6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING ' AUTOMATIC LINE LEAK DETECTOR I� ' LINE TIGHTNESS TESTING ❑ 3 ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES _ NO D. CORROSION ❑ 1 POLYETHYLENE WRAP a 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE �1115 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. BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION AG) 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A(D 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 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 ' AUTOMATIC LINE LEAK DETECTOR I� ' LINE TIGHTNESS TESTING ❑ 3 ❑ 99 OTHER u MOITAL NITORING V. TANK LEAK DETECTION Ev?�1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING a 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING 04 TANK TESTING ❑ 7 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 Lj SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BES MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME DATE (PRINTED 8 SIGNATURE) J/ Z•zt -9'L LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOURRUMBERS BELOW COUNTY # JURISDICTION # FACILITY # TANK # STATE I.D.# �,IAZ PERMIT NUMBER Ir PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. F01IM4B-R5