COMPLIANCE INFO_1996-1999 DOUBLE CHECK

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0 • s STATE OF CALIFORNIA 'F . `O t; STATE WATER RESOURCES CONTROL BOARD ; UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B� j y 0. COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED64= PE MIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED I DBA OR FACILITY NAME WHERE TANK IS INSTALLED: (5v �� S AC o:2 - ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE I. 1 ANN UCo%,nir I IVIY GUMPLt I t ALL 11 tMA" - SPtGII-Y It UNKNUWN A. OWNER'S TANK 1. D. 0 i 2 a _ B. MANUFACTURED BY: C. DATE INSTALLED (MO/DAY/YEAR) q� D. TANK CAPACITY IN GALLONS: ILTANKCONTENTS IFA -1 IS MARKED. COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL 4 OIL l ❑ B. 3 DIESEL C. ❑ 6 AVIATION GAS ❑ 1aREGULAR UN UNLEADED ❑ 2 PETROLEUM ❑ 60 EMPTY ® 1 PRODUCT 1b PREMIUM 4 GASAHOL ❑ 7 METHANOL UNLEADED JL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99OTHER(DESCRIBE IN ITEM D. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. III: III_ TANK CONSTRUCTION MARK ONF ITEM ONl Y IN ROXFS A. R AND C. AND ALL THAT APPL IFS IN ROX D AND;: A. TYPE OF � 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER 1 SINGLE WALL ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL 'tel 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC 8. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOP ❑ 5 GLASS LINING � 6 UNLINED El UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES -V/-NO D. CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP Tr'4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) �y OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) l IV. PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND. BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A 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 CORROSION PROTECTION A U A U A U i BARE STEEL 5 ALUMINUM 9 GALVANIZED STEEL A U A U A U 2 STAINLESS STEEL A U 6 CONCRETE A U 10 CATHODIC PROTECTION 3 POLYVINYL CHLORIDE(PVC)A®4 FIBERGLASS PIPE 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION Mol, AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING Ir 3 MONFTORING ❑ 99 OTHER V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 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 S ❑ ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL ?h0 No THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPUGAN FS NAME (PRINTED It SIGNATURE) ( 1 v LOCAL AGENCY USE ONLV THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # a` OI 0 TANK # STATE I.D.# ❑ PERMIT NUMBER PERMIT APPROVED BY/OATE PERMIT EXPIRATION DATE Ot 614 ( THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION . FORM A. UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH SOCAL AGENCY IMPLEMENTING THE UNDERGROUND STIDE TANK REGULATIONS FORM B (12-91)