COMPLIANCE INFO_1991-1994 - Laserfiche WebLink

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STATE OF CAUFORMA AP 600�e's C° STATE WATER RESOURCES CONTROL BOARD°o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY ELK1' 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:lv4j1;L.L.--TI ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC QVA ❑ 5 CONCRETE I. TANK DESCRIPTION COMPLETE ALL ITEMS - SPECIFY IF UNKNOWN A. OWNER'S TANK I. D. A B. PRODUCT B. MANUFACTURED BY: �' �� /�� ` I �J �1 C. DATE INSTALLED (MO/DAY/YEAR) 6-91 amu D. TANK CAPACITY IN GALLONS: 12 II. TANK CONTENTS IFA -1 IS MARKED. COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. PRODUCT C. ❑ la REGULAR3 DIESEL ❑ 6 AVIATION GAS 1bP MIUM ❑ 4 GASAHOL 7 2 PETROLEUM ❑ 80 EMPTY SYSTEM ❑ ❑ METHANOL NLEADED ❑ 5 JET FUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN O 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 ONE ITEM ONLY IN BOXES A_ B. AND C. AND ALL THAT APPLIES IN BOX D A. TYPE OF 7�171 DOUBLE WALL F—] 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER 1 SINGLE WALL F-11 BARE STEEL F-]2 STAINLESS STEEL ❑ 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 ❑D LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR F75 GLASS LINING UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING ❑ 3 INTERSTITIAL MONITORING ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 1009/6 METHANOL? YES_ NO D. CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND. BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A 0 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A W 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC)A W4 FIBERGLASS PIPE C. MATERIAL AND CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 6 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING ❑ 3 INTERSTITIAL MONITORING ❑ 99 OTHER V. TANK LEAK DETECTION 1 ISUAL CHECK 2 INVENTORY RECONCILIATION3 VAPOR MONITORING 52"4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ESO6 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 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 APPLICANTS NAME �2&4-//^^ DATE (PRINTED&SIGNATURE)�1�➢�' Ci/°� .1. ai (Ai_.a.. � i � -,y_,� .J� i�,� LOCAL AGENCY USE ONLY THE - THE STATE I.D. NUMBERS COMPOSED OFT FOUIR-SN1I iMRr-RS BELOW w�c�+ ` �� COUNTY # JURISDICTION # FACILITY # TANK # STATE I.D.# m PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORMS (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. FOR00348•R4