COMPLIANCE INFO_1996-1999 - Laserfiche WebLink

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STATEOFcAuFoRtaA •� .,,� STATE WATER CES CONTROL OAA UNDERGROUND STORAGE TANK PERMIT APjPUCATI,ON-FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. .�"®°'•"•. t/ MARK ONLY 1 NEW (� s RENEWAL PERMIT' g CHANGE OF INFORMATION0 ONE ITEM ® 2 INTERIM PERMIT ® 4 AMENDED PERMIT ® 6 TEMPORARY TANK CLOSURE ® 7 Y CLOSED ON a 6 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: /7'jeb G L TANK DESCRIPTION COMPLETE AM ITEMS_SPEgFY 9:UNKNOWN A-OWNERS TANK L O.1 3 B.MANUFACTURED BY. C DATE INSTALLED(MptDgv/YEgR) 3 �� D.TANK CAPACITY IN GALLONS: IL TANK CONTENTS IFA 1 IS MARK,COMPLY ITEM C. 4 OIL A. ® 1 MOTOR VEHICLE FUELM O.Baow)® � EMPTY 1 PRODUCT e C. Is REGULAR UNLEADED 3 Geral ® 6 AVIATION GAS ED PETROLEUM tb PRt3."UNLEADED ❑ 4 METHANOL ® 3 CHEMICALFRODUCT E) 95 UNKNOWN ® WASTE 1C M UNLEADED 5 JET FUEL ❑ 6 MBS ❑ ❑ 99 OTHER(DESCRIBE Id ITE O. IF(a1)IS NOT MARKED.ENTER NAME OF SUBSTANCE STORED 2 LEADED C.A.S.III: III. TANK CONSTRUCTION MAR(ONE ffEM ONLY IN AXES A.B.AND C.AND ALL THAT APPLIES IN BOX D AND E A.TYPE OF lel I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTEAIoR LINER ® 5 INTERNAL BLADDER SYSTEM SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER C:] 95 UNKNOWN 8. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM E] 6 100% METHANOL FAY TAW C:] 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN 99 OTHER COMPATIBLE WA RP C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD UMNG ❑ 3 EPDXY UNNG ® 4 PHENOUC LINING LINING OR ❑ 5 GLASS UNING 6 UNLINED ❑ 95 UNKNOWN 99 OTHER COATING IS UNING MATERIAL COMPATIBLE WITH 100% METHANOL? YES„S4 NO_ D CORROSIONBOSTON RIOR F-11 POLYETHYLENE WRAP E] 2 COATING ❑ ��++ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,6t0. SPILL CXNtT NNMEMf ALLED(YEAR) OVERALL PREVENTION EQUIPMENT �00N=�YES RIKER PLATE YES NO NO N.PIPING INFORMATION dHCLE A IF ABOVE 9MMDOR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U / SUCTIO��PRESSURE A U 3 GRAVITY A U 4 Ft EXIBLE PIPING A U 99 OTHER ®. CONSTRUCTION A U 1 SINGLEDOUBLE 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 CORROSION A U 5 ALUMINUM (PVGyA 4 FIBERGLASS PIPE A U 6 CONCRETE A U 7 STEEL W/COATING ll A U PROTECTION A U 9 GALVANIZED STEEL q U 10 CATHODIC PROTECTION 6 11 METHANOL COMPATIBLE W/FRP A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 eTE amcAt ul LFAK 2 o�u nruL ❑rIM TESTING 4 t»e AUT0110ATIC PUW c + ❑ V.TANK LEAK DETECTION "MOWN 99 OTHER WVISUAL CHECK ❑ 2 RECONCILIATTIIONORY ❑ 3 M BORING 4 GAUGOINAGC TANK ❑5 GROUND WATER ❑6 ANNUALTANK CONTINUOUS INTERSTITIAL RZ1 6 SIR ❑ 9 WEEKLY MANUAL ❑10 MONTHLY TANK MONITORING WN TESTING MONITORING �-T TANK GAUGING TESTING ❑ 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) AZ 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF SUBSTANCE REMAINING 3•WAS TANK AILED WITH YES ❑ NO❑ GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNERS NAME (PRINTED b SIGNATURE) '(�� DATE ) 3 � LOCAL AGENCY USE ONLY THE STATE I.D.N MBER IS COMPOSED OF THE FOUR MBERS BELOW STATE 1.D.'# COUNTY M JURISDICTION N FACILITY 4 TANK# � LPERIVTUMBER PERMIT APPROVED BY/DATE PERMIT 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 FORMS (6-95)SHOULD BE ACCOMPANIED BY A PLOT PLAN. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE-UNDERGROUND STORAGE TANK REGULATIONS