COMPLIANCE INFO_1995-2011 - Laserfiche WebLink

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0 6g Ncg STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD , UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM Bp; •c,IIPORN�'` COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ® 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ® 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 'C I. TANK DESCRIPMON COMPLETE ALL ITEMS- SPE IFY IF UNKNOWN A. OWNERS TANK 1.D.# ,Jw B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) L n D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A ❑ 9 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. Lj to REGULAR UNLMED ❑ 3 DIESEL ❑ 6 AVIATION GAS ® 2 PETROLEUM ® 80 EMPTY 1 PRODUCT ❑ lb PREMIUM UNLEADED ® 4 GASAHOL ❑ 7 METHANOL ® tc M E UNLEADED 5 JET FUEL ❑ 8 M85 3 CHEMICAL PRODUCT ® 95 UNKNOWN ® 2 WASTE ❑ 2 LEADED H 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(A1)IS NOT ,ENTER NAME OF SUBSTANCE STORED �` f� C.A.S.#: 5 %Z/ III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN SORES A,B,AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF ❑ i DOUBLE WALL ® 3 SINGLE WALL WITH EXTERIOR UNER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ® 3 FIBERGLASS ® 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ® 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FR® ftimity Tank) ® 9 BRONZE ❑ 10 GALVANIZED STEEL ® 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ® 2 ALKYD LINING ® 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 6 UNLINED 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ® 3 VINYL WRAP ® 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONEEj?L95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,et0 SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES NO STRIKER PLATE YES NO DISPENSER CONTAINMENT YES NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 9 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A 99 OTHER B. CONSTRUCTION Ao 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL coMPAnBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION 95 UNKNOWN A U 99 OTHER 1 CAL L LEAK 2 Ufa 70MESS 3 4 LINE 5 AUTOMATIC PUMP D. LEAK DETECTION ❑ DETECMR ❑ TESnNa ® ® exAK cTOR ® SHUTDOWN E] as DITHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ® 2 RREECCOUNNCWIIATIIONORY ❑ 3 V MONITORING ® 4 GAUGINAUTOMATIC TANK ❑5 MONITORINGROUND WATER 716 TESTINGNUAL TANK ® 7 CO NSU US INTERSTITIAL [18 SIR ❑ 9 WEEKLYA UGINQ MANUAL ®10,M�OSNTHLLY TANK 95 UNKNOWN ®99 OTHER ING TANKVI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATE DAUE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF3.WAS TANK FILLED WITH t f SUBSTANCE REMAINING S' GALLONS INERT MATERIAL? YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNERS NAME - ov FORDATE (PRINTED&SKINATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.4 m I I 1 1 Tu PERMIT NUMBERPERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE Li -- I THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLO N. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENITING THE UNDERGROUND STORAGE TANK REGULATIONS FORMS (695)