COMPLIANCE INFO_1994-2001 - Laserfiche WebLink

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• � �ypURCp4 STATE OF CALIFORNIA p ca p STATE WATER RESOURCES CONTROL BOARD w, UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B \ Cit IFOn N`� COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITZ ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED rERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I_ TANK DESCRIPTION COMPLETE ALL ITEMS -- SPECIFY IF UNKNOWN I A. OWNER'S TANK 1. D. * O B. B. MANUFACTURED BY: �oA)--c444 C. DATE INSTALLED (MO/DAY/YEAR) IN 1 PRODUCT D. TANK CAPACITY IN GALLONS: /4/ pco II TANK rONTFNTS IC AA IR MARKED C(1MPI FTP ITEM C_ �(—� 1 MOTOR VEHICLE FUEL ❑ 4 OIL A _❑ B. C. 1- REGUD LAR ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 4 GASAHOL 2 PETROLEUM O 80 EMPTY IN 1 PRODUCT ❑ ib PREMIUM ❑ 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. #: III TANK rOKIRTM ICTION MARK ONF ITEM ONI YIN ROXFS A R AND C. AND ALL THAT APPLIES IN ROX D AND F A. TYPE OF1 DOUBLE WALL �2 F--]3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER 1 SINGLE WALL F--]1 BARE STEEL ❑ 2 STAINLESS STEEL F—]3 FIBERGLASS 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC B. TANK 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 LINING9 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100'/ METHANOL? YES NO Gr, ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP5:j- � l 4 FIBERGLASS REINFORCED PLASTIC D. CORROSION ``❑ PROTECTION PROTECTION E:]5 CATHODIC PROTECTION ❑ 91 NONE ID 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. BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A 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 CORROSION PROTECTION A U A U A U 1 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® 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 ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 IMNOTE STITIA ❑ 99 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 ❑ 99 OTHER VI. TANK CLOSURE INFORMATION 1. ESTIMATE AT LAST E,: O/DAY/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH /�/1 SUBSTANCE REMAINING GALLONS INERT MATERIAL ? YES NO THIS FORM WS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE SPRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # TANK # STATE I.D.# 'ERMIT 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 WRHLOCAL AGENCY IMPLEMENTING THE UNDERGROUNDS i NDERGROUNDST E TANK REGUL7---- FORM B (12-91)-� 00346-R6