COMPLIANCE INFO_1996-1999 - Laserfiche WebLink

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6b��OCt STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD o UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B � , •C�l,RO„N•R COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. pp'� MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE oil MARK ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 'lue-0 /=rte%Gr i?y 2/37 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.• Z UNGQ�Q B. MANUFACTURED BY: �Q/JE2n/ 61/G-'Lp/N C. DATE INSTALLED(MO/DAY/YEAR) ,� D. TANK CAPACITY IN GALLONS: �2 II.TANK CONTENTS IF A•1 IS MARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL a 4 OIL B, C to REGULAR UNLEADED O 3 DIESEL ❑ 6 AVIATION GAS Q❑ lb PREMIUM UNLEADED ❑ 4 GASAHOL Q 7 METHANOL 2 PETROLEUM ❑ BO EMPTY 1 PRODUCT ❑ lc MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELO" D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.III: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF ,IPSL 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 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/FRP (Pri-WT-k) ❑ 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 CORROSION 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,etc. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES__$_e 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 1 SUCTION A PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A(92 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&)4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% 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 01 Lm LEAK Q 2 UNE TICHINM [g3 OMTIMIOUS INIERSTMAL [:]4 ELECTROMC UNE 05 AVrOMATIC PUMP E]s9 OTHER TESTRKI MOMTORUIG LEAK DETECTOR SHUTWM V.TANK LEAK DETECTION (❑ 1 VISUAL CHECK ❑ 2 RECONCILIATION ONCILIUAL �ONORY � 3 MONITORING ❑ 4 GAUGING C TANK ❑5 GROUND WATER �6 ANNUNGTANK �`�' 7 MONITORING NUOUS INTERSTITIAL � 8 SIR ❑ 9 WEFIANK GA=AL ❑t0 T STINGY TANK ❑ 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING 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 OWNER'S NAME ' ///�� ' 9 DATE 1 LL I (PRINTED 6 SIGNATURE) i' ry` ( �(J M Z. / LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSE E FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D:# m FTTI (-T�3iAlelf� PERMIT NUMBER PERMIT APPROVED BY/DATE LPERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLAN. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORMS (6.95)