COMPLIANCE INFO_1991-1994 - Laserfiche WebLink

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• 0 STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FORE H TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE DBA OR FACILITY NAME WHERE TANK IS INSTALLED: g�ieq (,/lig% jote-& GQW I. TANK DESCRIPTION COMPLETE ALL ITEMS -- SPECIFY IF UNKNOWN P�SpURCEs C P OA 9 tl ids cel FOP N.� ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 8 TANK REMOVED I I A. OWNER'S TANK L D. # P- el B. MANUFACTURED BY: Gr Al C a REGULAR ❑ 3 DIESEL ❑ 6 AVIATION GAS UNLEADED ❑ q GASAHOL C. DATE INSTALLED (MO/DAY/YEAR) 9 D. TANK CAPACITY IN GALLONS: W I ' II.TANKCONTENTS IFA -1 IS MARKED. COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL 4 OIL B. C a REGULAR ❑ 3 DIESEL ❑ 6 AVIATION GAS UNLEADED ❑ q GASAHOL F-]2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ lb 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 CONSTRUCTION MARK MP ITEM ()NI Y IN ROXFR A R ANP) C ANTI Al I THAT APPI IFR IN RC)Y In aNr) 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 1 SINGLE WALL ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS [::] 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC S. TANK 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 /0 CATHODIC PROTECTIONA MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE n-XMMINUM ❑ 8 1009/6 METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL uz 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING F-] 4 PHENOLIC LINING C. INTERIOR ❑5 GLASS LINING ❑ 6 UNLINED 96 ) - UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO D. CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑INYL WRAP El 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE n 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 TANK # RESSURE A U 3 GRAVITY A U 99 OTHER S. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH p U�5 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 /0 CATHODIC PROTECTIONA 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP 5 UNKNOWN A U 99 OTHER D. LEAK DETECTION E:]1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 MINERS RING ❑ 99 OTHER V. TANK LEAK DETECTION ❑1 yJSUAL CHECK INVENTORY RECONCILIATION F-]3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING I 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 El SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME DATE (PRINTED a SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION - FORM A, UNLESS A CURRENT FORM A HAS BEEN -FILED. 0 0 �Kv FOR003411145 COUNTY # JURISDICTION # FACILITY # TANK # STATE I.D.# ❑m PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE�- �_ `Z FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION - FORM A, UNLESS A CURRENT FORM A HAS BEEN -FILED. 0 0 �Kv FOR003411145