COMPLIANCE INFO_1994-2001 - Laserfiche WebLink

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STATE OFCAUFORMA STATE WATER RESOURCES CONTROL BOARD �.• `p> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM } EMARKLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT5 CHANGE OF INFORMATION ❑M ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT 7 PERMANENTLY CL 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVACILITY NAME WHERE TANK IS INSTALLED: 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK 1.D.s B. MANUFACTURED BY; C. DATE INSTALLED(MO/DAY/YEAR) - 154 0. TANK CAPACITY IN GALLONS; II.TANK CONTENTS IFA-t IS MARKED.COMPLETE ITEM C. v A. 1 MOTOR VEHICLE FUEL 4 OIL g. C. �t to REGULAR 3 DIESEL 2 PETROLEUM ❑ 60 EMPTY (�Q 1 PRODUCT t)aG tb PREMIUM ❑ 6 AVIATION GAS ` 4' d GASAHOI ❑ 3 CHEMICAIPRODUCT 95 UNKNOWN ❑ 2 WASTE 2UNLEADED 5 JET FUEL ❑ 7METHANOI ❑ DED 99 OTHER (DESCRIBE IN ITEM 0. BELOW) D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.s III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOX 0 AND E 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 ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ s STEEL CIAO W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 10O% METHANOL COMPATIBLE W/FAP (Primary Tank) (� 9 BRONZE ❑ 10 GALVANIZED STEEL I� 95 UNKNOWN ❑ gg OTHER ❑ t RUBBER LINED ❑ 2 ALKYO LINING C.INTERIOR �1 ❑ 3 LINING ❑ 4 PHENOLIC LINING LINING I_• 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION I--_; 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN❑ ❑, 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) 11 OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) dqi _ IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE 7CONSTRUCTION E A U 1 SUCTION 2 PRESSURE A U 3 GRAVITY A U 99 OTHER A U 1 SINGLE WALL A� DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER ND A U I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE P A U S ALUMINUM A U B CONCRETE ( 4 FIBERGLASS PIPE A u 7 STEEL wi CQAnNG A U 6 100%METHANOL COMPATIBLE W/FRP 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 UNE TIGHTNESS TESTING MONRQRING ❑9D OTHER V.TANK LEAK DETECTION 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ A AUTOMATIC TANK GAUGING❑ 5 GROUNDWATER MOM - 6 TANK TESTING 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER TO VI.TANK CLOSURE INFORMATION I.ESTIMATED DATE LAST USED(MO/OAY/YR) I 2.ESTIMATED QUANTITY OF SUBSTANCE REMAINING3.WAS TANK FILLED WITH GAYES n NO❑ GALLONS ,NERTMATERIAL? TH/S FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME (PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# STATE 1.04TANK# �b PERMIT NUMBER / PERMIT APPROVED BY/OATS f PERMIT EXPtRAT10N DATE I J_ THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM B (72.91) FILE THIS FORM WITH i HE Lr- 'l AGENCY IMPLEMENTING THE UNDERGROUND STr 4RAC NK REGULATIONS • • -7- •�') !y )FORORN846