COMPLIANCE INFO_1994-2001 - Laserfiche WebLink

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g. 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 8 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ® 2 INTERIM PERMIT 4 AMENDED PERMIT 0 TEMPORARY TANK CLOSURE E:] 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: �� _ l �� J �~'F, ex/ �c 1 I. TANK DESCRIPTION COMPLETE ALL ITEMS -• SPECIFY IF UNKNOWN A. OWNER'S TANK I. D. # �)Z B. MANUFACTURED BY: �^ � C. DATE INSTALLED (MO/DAY/YEAR) (� D. TANK CAPACITY IN GALLONS: i IL TANK CONTENTS IFA-11SMARKED.COMPLFTFITFM C. A i MOTOR VEHICLE FUEL ❑ 4 OIL B. 'Xi C• I F --la REGULAR ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY PRODUCT ❑ ib PREMIUM UNLEADED ❑ 4 GASAHOL ❑ J ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑❑��'� 2 WASTE ❑ 2 LEADED 9 9 OTHERET ❑ (DESCRIBE IN ITEM D. BELOWY D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED (Primary Tank) C. A. S. # `. ❑ 10 GALVANIZED STEEL III. TANK CONSTRUCTION MARK ONF ITFM ON[ Y IN ROXFS A R AND C AND At I THAT APPI IFS IN ROY r1 ANn F 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 B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 1009% METHANOL COMPAT,JBLE W/FRP (Primary Tank) ❑ 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 ❑5 GLASS LINING �.6 UNLINED F__195 UNKNOWN ❑ 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 ❑ 95 UNKNOWN ❑ 99 OTHER E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) `IV. PIPING INFORMATION CIRCLE A IF ABOVE GROLIND OR U IF [)NDFRGROI IND ROTI -I IF APPI Ir.ARI G A. SYSTEM TYPE A U 1 SUCTION U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A 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 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) U,,.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 _I-1 AUTOMATIC LINE LEAK DETECTOR, ❑ 2 LINE TIGHTNESS TESTING 3 IN E STITIAL gg OTHER MONITORING ❑ TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORINI ❑ 6 TANK TESTING 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑, 95 UNKNOWN ❑ 99 OTHER A TANK CLOSURE INFORMATION 3 FESTIMATED DATE LAST USED (MO/DAY YR)2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES [:]NOSUBSTANCE REMAINING GALLONS INERT MATERIAL? DATE LAST USED (MO/DAY/YR) THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF RJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT (' APPLICANTS NAME ppp ,,fff'''�� DATE .. (PRINTED 8 SIGNATURE) 4 LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW /� ,• ( -( s COUNTY # JURISDICTION # FACILITY # TANK # STATE 04�, ,? r ,. � PERMITNUMBER PERM IT APPROVED BY/DATE PERMIT EXPIRATION DATE i 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) FOR003413-R6