COMPLIANCE INFO_1986-1996 - Laserfiche WebLink

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• STATE OF CALIFORNIA • 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 E5 CHANGE OF INFORMATION ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 1A2(,O F -AL_ N0. OSy $,(pl� I. TANK DESCRIPTION COMPLETE ALL ITEMS -- SPECIFY IF UNKNOWN ❑ 7 PERMANENTLY CLOSED ❑ 8 TANK REMOVE3;.F A. OWNER'S TANK I. D.#F L4- UML- 'P B. MANUFACTURED BY: V 114 1�-lo"hI C. DATE INSTALLED (MO/DAY/YEAR) os / - /&(P D. TANK CAPACITY IN GALLONS: O0o ILTANKCONTENTS IFA -1 IS MARKED. COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL 4 OIL ❑ B. ❑ 1aUN UNLEADED 3 DIESEL C, 6 AVIATION GAS ❑ 2 PETROLEUM 80 EMPTY �1 PRODUCT ©/� PREMIUM ❑ 4 GASAHOL 7 METHANOL UNLEADED ❑ 5 JET FUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 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 ❑ 1 DOUBLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM E2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK E�J-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 (PrfmaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER 6 CONCRETE A U ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING �� UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING LJ AUTOMATIC LINE LEAK DETECTOR Ej�jl LINE TIGHTNESS TESTING ❑ 3 ❑ 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 ❑ 5 CATHODIC PROTECTION ❑ 91 NONE E�j25 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 AID 2 PRESSURE A U 3 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 AO 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 LJ AUTOMATIC LINE LEAK DETECTOR Ej�jl LINE TIGHTNESS TESTING ❑ 3 ❑ 99 OTHER MONITORING 1. TANK LEAK DETECTION lkl1 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 ❑ 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 UNDER PENALTY OF PERJURY, AND TO THE WT OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED a SIGNATURE) 'BIS I A" I-.%tc.0 I.1 E2 k 2 -Zl • (? 2. LOCAL AGENCY 1.15E ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE I.D. COUNTY # JURISDICTION # FACILITY # TANK # ® PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE ov FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION - FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED, FOR0034&R5