COMPLIANCE INFO_1987-2001 - 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 FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT Ce5 CHANGE OF ICKCL T ONE ITEM (❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT a 6 TEMPORARY RE 8 T DBA OR FACILITY NAME WHERE TANK IS INSTALLED: QQ4_p F%4<- �.10, 5 L4GO I. TANK DESCRIPTION COMPLETE ALL ITEMS -- SPECIFY IF UNKNOWN INENTLY CLOSED ON SITE REMOVED �i j'` A. OWNER'S TANK I. D. x 3- 1 B. MANUFACTURED 3Y: ovtE+�.s co rZ,.► 1 tl y C. DATE INSTALLED (MO/DAY/YEAR) 10 /� / D. TANK CAPACITY IN GALLONS: iZ oOO II. TANK CONTENTS IF A•1 IS MARKED. COMPLETE ITEM C. A ❑ MOTOR VEHICLE FUEL ❑ 4 OIL 8. C. ❑ Ia=-GULAUNLEADED 3 DIESEL El6 AVIATION GAS 2 PETROLEUM ❑ 80 EMPTY - I PRODUCT Cyi!'p PREMIUM 4 GASAHOL 7 METHANOL UNLEADED El5 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. x: III. TANK CONSTRUCTION MARK ONE ITFM ONLY IN ROXFS A R AMO C AMn AI I THAT APPI ICQ I M CnY rl A Kill C A. TYPE OF I-1 I 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 �I: ' FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC 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 ❑ 2 ALKYD LINING F73 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING C�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 ❑� 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 UNOFRGROLINn RnTH IF APPI Icealc A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL 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) ACS 4 FIBERGLASS PIPE 7 S TEELW/COATING A U 8 100°i METHANOL COMPATIBLEWiFRP A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION E AUTOMATIC LINE LEAK DETECTOR [:]2 LINE TIGHTNESS TESTING INTERSTITIAL MONITORING El 99 OTHER V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING 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 APPLICANT'S NAME (PRINTED d SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR Nd'MBERS BELOW STATE I.D.# 1� COUNTY # JURISDICTION # FACILITY x TANK # EFTFT- C ? PERMIT NUMBER PERMIT APPROVED BY/DATE i PERMIT EXPIRATION DATE FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. OR007.1 B -R5