COMPLIANCE INFO_1993-1998 - Laserfiche WebLink

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tS yUrtcPs STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B `A Il! COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ,s`t NEW PERMIT a 3 RENEWAL PERMIT F-] 5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE a 8 TANK REMOVED Q' V DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Z.-' _ LeJ f7- ❑ 5 CONCRETE I. TANK DESCRIPTION COMPLETE ALL ITEMS -- SPECIFY IF UNKNOWN A. OWNER'S TANK I. D. # ' B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) 94 D. TANK CAPACITY IN GALLONS: 12 p0(> f II. TANK CONTENTS IFA -1 IS MARKED. COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C.❑ 1. REGULAR LEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 1b PREMIUM ❑ 4 GASAHOL ❑ 7 METHANOL UNLEADED ❑ JET L E]3 CHEMICAL PRODUCT F-]95 UNKNOWN ❑ 2 WASTE ❑ 2 EADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED Plus V/ L C. A. S. #: III. TANK CONSTRUCTION MARK ONE ITEM ONLY INBOXES A, B, AND C, AND ALL THAT APPLIES IN BOX D AND E -� K �d f 1 G 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 F-]1 BARE STEEL F-]2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 1009/6 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. INTERIOR F-]5 GLASS LINING 6 UNLINED F795 UNKNOWN E]99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES _ NO D. CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 0<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 GROUND OR U IF UNDERGROUND. BOTH IF APPLICARI F A. SYSTEM TYPE A U 1 SUCTION 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL Als)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 2 STAINLESS STEEL A U A U 6 CONCRETE A U A U 10 CATHODIC PROTECTION 3 POLYVINYL CHLORIDE (PVC) Al(m> 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 X 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 MOLAR TERSTITIARING ❑ 99 OTHER V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING a 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER 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 SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES ❑ NO ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED 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.# I Iy PERMIT 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 WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (12-91) • �� > /'