COMPLIANCE INFO_1986-1997 - Laserfiche WebLink

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gOURCt3 � STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B •C1t IIOR M�� COMPLETE A SEPARATE FORM FORE CH TANK SYSTEM. MARK ONLY O 1 NEW PERMIT a 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM � 2 INTERIM PERMIT 4 AMENDED PERMIT a 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ✓ Z, I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: �J II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A1 MOTOR VEHICLE FUEL 4 OIL B. C Q eta REGULAR UNLEADED Q 3 DIESEL ED 6 AVIATION GAS 2 PETROLEUM 80 EMPTY EZ 1 PRODUCT 1b PREMIUM UNLEADED a 4 GASAHOL ED 7 METHANOL O is MIDGRADE UNLEADED ED 5 JETFUEL ED 8 M85 a 3 CHEMICAL PRODUCT a 95 UNKNOWN 2 WASTE O 2 LEADED ED 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: 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 F--j 1 DOUBLE WALL F--� 3 SINGLE WALL WITH EXTERIOR LINER 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM 0 2 SINGLE WALL F1 4 SINGLE WALL IN A VAULT 99 OTHER B. TANK F7 1 BARE STEEL 0 2 STAINLESS STEEL a 3 FIBERGLASS [D 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL F--] 5 CONCRETE EJ 6 POLYVINYL CHLORIDE 0 7 ALUMINUM a 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) � 9 BRONZE 10 GALVANIZED STEEL � 95 UNKN N a 99 OTHER C.INTERIOR F] 1 RUBBER LINED 2 ALKYD LINING 3 E XY LINING 0 4 PHENOLIC LINING LINING OR 5 GLASS LINING ❑ 6 UNLINED F-1UNKNOWN 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR 1 POLYETHYLENE WRAP F-] 2 COATING 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION Ej 5 CATHODIC PROTECTION E:] 91 NONE 95 UNKNOWN 0 99 OTHER E.SPILL AND OVERFILL,CIC. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES NO FAKER PLATE YES NO DISPENSER CONTAINMENT YES NO IV.PIPING INFORMATION CIRCLE A IF ABOV@'GR416N R U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A RESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A 2- DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL 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 COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED EEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 MECHANICAL UNE O 2 UNE TIGHTNESS ED 3 CONTINUOUS INTERSTITIAL ❑4 ELECTRONIC LINE ❑5 AUTOMATIC PUMP ❑ 99 OTHER DETECTOR TESTING MONITORING LEAK DETECTOR SHUTDOWN V.TANK LEAK DETECTION 1 VISUAL CHECK 2 MANUAL RECONCILIATION MONITORING TANK 3 MONITORING a 4 GAUGING IC TANK 5 MONITORING TER 6 TESTING E] 7 MONITOR CONTINUOUS a 8 SIR a 9 WEEK LY MANUAL 10 MO TINLY TANK 95 UNKNOWN 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES 0 NO SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D:# PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLIC ON-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 PILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE&GROUND STORAGE TANK REGULATIONS FORM B (6-95)