COMPLIANCE INFO_1994-2001 - Laserfiche WebLink

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0 STATE OFCAUFORMA UNDERGROUND STATE WATER STORAGE TANK PERMITSOURCES CONT BOARD 4uun��' T APPLICATION.FORM B MARKONLY COMPLETE A SEPARATE FOR ONE ITEM 1 NEW PERMIT M FOR EACH TANK SYSTEM• 2 INTERIM PERMIT ❑ 3 RENEWAL PERMIT NA i,�' DBA OR FACILITY 4 AMENDED PERMIT 5 CHANGE OF INFORMATION NAME WHERE TANK IS IN a TEMPORARY TANK CL ❑ 7 PERMANENTLY CLOS I• TANK DESCRIPTION STALLED• CLOSURE ❑ a TANK REMOVED A. OwNER�s TANK I.p,�, COMPLETE ALL ITEMS—SPECIFY IF UNKNOWN ` � C• DATE INSTALLED(MO/OAy/YEAR) MANUFACTURED BY: A. M If.TANK CONTENTS \ D. TANK CAPACITY IN IFA-1 ISMARKED.COMPLETE ITEM C. GALLONS., 1 OTOR VEHICLE FUEL e� ❑ 2 PETROLEUM ❑ 4 Oil 8. ❑ 3 CHEMICAL PflODUCT ❑ 80 EMPTY C. ❑ Ia(A`GULAR 1 PRODUCT 1 3 DIESEL D. IF(A.1)IS NOT MARKED, ❑ 95 UNKNOWN ib PREMIUM � 4 GASgHOL ❑ a AVIATIONGAS � ENTER NAME OF SUBSTANCE STORED ❑ 2 WASTE (� UNLEADED III. TANK 2 LEADED 5 JETFUEL ❑ 7 METHANOL CONSTRUCTION �-- 99 OTHER (DESCRIBE IN i MARK ONE ITEM ONLY IN BOXES A, ITEM! 0• BELOW) A. TYPE OF 1 DOUBLE WALL 8,AND C, C.A S. SYSTEM AND ALL THAT APPLIES IN BOX O AND E d 2 SINGLE WALL Q 3 S 'LE WAIL WITH EXTERIOR LINER 04 SECONDARYCONTAINMECD95 UNKNOWN NT B• TANK L 5 CONCRI BARE STEEL (VAULTED TANK) MATERIAL L_I 2 STAINLESS STEEL ❑ 99 OTHER (Primary Tank) ❑ ETE 3 FIBERGLASS E:19 BRONZE u a 'POLYVINYL CHLORIDE (� 7 ❑ 4 STEEL CLgO Wj FIBERGLASS REINFORCED ❑ ❑ 10 GALVANIZED STEEL PLASTIC ) C.INTERIOR 1 RUBBER LINED ❑ 8 L00% 'METHANOL COMPATIBLE WI f (� ❑ 2 ALKY —� 95 UNKNOWN ❑ 99 OTHER LINING `�f 5 GLASS LINING ° LINING EA ; (� �— 3 EPDXY LINING IS LINING MATERIAL �- 8 UNLINED ❑ 4 PHENOIX; COMPATIBLE WITH 1 ❑ 95 UNKNOWN LINING D.CORROSION 00%'METHANOL t YES ❑ 99 OTHER � ❑ 1 POLYETHYLENE WRAP "— NO PROTECTION ❑ 2 COATING ❑ 5 CATHOpIC PROT °.SECT1Ory 91 ❑ 3 VINY PILL AND OVERFILL L WRAP NONE SPILL CONTAINMENT INSTALLED(YEAR) < FIBERGLASS REINFORCED PLASTIC ❑a5 UNKNOWN V.11 11 P111 IPING INFORMATION -- 99 OTHER CIRCLE A IFASOV OVERFILL PREVENTION SYSTEMTYpE A U t SUCTION OVERFILL U IFUNDERGROUND.80 EOUIPMENTINSTALLEp(YEAR) 71 CONSTRUCTION TH IFAPPLICABLE ' A U I SINGLE WALL U PRESSURE A U 3 GRAVITY MATERIAL AND A U / u DOUBLE WALL ! CORROSION BARE STEEL A U 3 LINED TRENCH A U 98 OTHER i PROTECTION A U 5 ALUMINUM A U 2 STAINLESS STEEL A U 95 UNKNOWN i A U 9 GALVANIZED S A U a CONCRETE A U 3 POLYVINYL CHLORIDE A U 99 OTHER LEAK DETECTION TEE- A U Io A U 7 STEELwicogn (PVC) FIBERGLASS PIPE 1 AUTOMATIC LINE CATHODIC PROTECTION NG ANK LEAK D LEAK DETECTOR A u 95 UNKNOWN A U a 7M% METHANOL DETECTION ❑2 LINE TIGHTNESS TESTING A U 99 OTHER COMPATIBLE w/FRP t VISUAL CHECK MONRORNG ❑99 OTHER 1 6 TANK TESTING 2 INVENTORY RECONCILIATION 7 INTERSTITIAL MONITORING 3 VADOZE MONITORING ! 'ANKCLOSUREINFORMATIO(V 91 NONE 4 auTOMAT)CTANKGgUGtNG T ❑ 95 UNKNOWN ❑ 5 GROUND WATER MONITORING IMATED DATE LAST USED(MO/Dgyryq) i ❑ 99 OTHER I 2.ESTIMATED QUANTITY OF >FORM HAS BEEN C SUBSTANCE REMAINING APPLICANTS SEAME OMPLETED UND ��GALLONS 3'WAS TANK FILLED WITH ER PENAL TY OF PE;q,�URY, INERT MATERIAL? YES !1 IPA��EO a SIGNq',Uq� AND T L_1 NQ� t O THE BEST OF Aol KNOWLEDGE /S L AGENCY USE ONLY �UEAND CORRECT THE STATE LD. DATE # NUMBER 1S COMPOSED OF THE FOUR NUMBERS BELOW STATE LD# couNTv# JURISDICTION# FAClUTy x ) LUMBER I + L TANK* PERMITAPPgpVED8Yi0ATE �] THIS FORM MUST BE ACCOMPANIED BY A PERMIT APP ! "`/ / I PERMIT EXPIRATION PATE 7 91) FILE THIS FORM WITH—4E LOCAL AGENCY IMP,cUCATiON- FORM A,UNLESS A CURRENT � MENTiNG THE UNDERGROUND ST(1RgGE K AEGAS P ��l r • FILED. I t 1 Foftll