COMPLIANCE INFO_1991-1994 - Laserfiche WebLink

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p�90UR ;8 C STATE OFCAUFORNIA :r •°. 9 STATE WATER RESOURCES CONTROL BOARD w �, UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. c""N MARK ONLY * [i; NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 19H GLL- Sce.ncjr:' 5--r4 j Iw 1 TANK nFRCRIPTION COMPLETE ALL ITEMS -- SPECIFY IF UNKNOWN A. OWNER'S TANK I. D. # IJ/- Wow ,I B. MANUFACTURED BY: . , Ic4owii C. DATE INSTALLED (MO/DAY/YEAR) iV D. TANK CAPACITY IN GALLONS: SC)r-p>(a 11 TANK(`nNTFNT.q IF: A.11sMARKEt1COMPIETEITEMC. A [q,-1 MOTOR VEHICLE FUEL F—]4 OIL B. C. ❑ 1a REGUL R ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 4 GASAHOL ❑ 2 PETROLEUM ❑ 80 EMPTY PRODUCT ❑ tbPREMIUM ❑ 7 METHANOL -UNLEADED ❑ 5 JET FUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 1 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S.1. # 111 TANK CnNRTRI ICTION MARK ONE ITEM ONLY IN BOXES A. 8. AND C. AND ALLTHAT APPLIES IN BOX D 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 A U 2 DOUBLE WALL A U 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 1009% METHANOL COMPATIBLE W/FRP CORROSION A U 5 ALUMINUM (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER A U 10 CATHODIC PROTECTION ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 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— D. CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 5 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A V2 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 V 95 UNKNOWN A U 99 OTHER A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE C. MATERIAL AND CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/ COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A 6>95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 MONITORING 99TERSTITIAL OTHER U"K4jC) W 4 V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE UNKNOWN ❑ 99 OTHER VI. TANK CLOSURE INFORMATION 1. ESTIMATED D TE LAST USED (MO/DAY/VR) 2. ESTIMATED BSTANCE REMAINING U_d KktXA+XJ GALLONS 3 WASINERT MATERIAL TANK FILLED YES Li NO ❑ �IKIkJ � SUREMAINING THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME 'y !!�[��jJ DATE (PRINTED&SIGNATURE) -)a MP��:IG`( I/�• i-_' / ,.p "I' �[�Q_ C�y,r�� S +_I _.q I LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # TANK # STATE I.D.# ❑ PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORM 8 (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. FOR00348-R4