COMPLIANCE INFO_1986-1997 - Laserfiche WebLink

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f. • .o0 R°t5 STATE OF CALIFORNIA AP r ` STATE WATER RESOURCES CONTROL BOARD W I oo m UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B ftl • CSL IRpR H.r COMPLETE A SEPARATE FORM FOR,EACH TANK SYSTEM. MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS N SI E ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED !✓\•/ DBA OR FACILITY NAME WHERE TANK IS INSTALLED: l ,—� 11 .3 �� 1-0 z- 1. 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: 3/1VUD 11.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A. ❑j1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C ❑ to REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT ❑)J;PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL 1c MIDGRADE UNLEADED 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 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 ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LIN17R ❑ 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 E:]V95 IBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL F__] 5 CONCRETE F__] 6 POLYVINYL CHLORIDE LUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) [:] 9 BRONZE El 10 GALVANIZED STEELUNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING3 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 NONE ❑ 95 UNKNOWN 99 OTHER E.SPILL AND OVERFILL,etc. 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 AB GROU OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WAL A U L DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUMU 6 CONCRETE A U 7 STEELCOATING 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 [:]1 MECHANICAL LINE LEAK 2 LINE TIGHTNESS E]3 CONTINUOUS INTERSTITIAL 4 ELECTRONIC LINE F--j 5 AUTOMATIC PUMP O 99 OTHER DETECTOR TESTING MONITORING LEAK DETECTOR SHUTDOWN V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL RECONCILIATIONORY E:] 3 VADOZE MONITORING ❑ 4 AUTOMATGAUGING IC TANK ❑5 GROUND MONITORING TER ❑ 6 TE NG ❑ 7 CONTINUMONITORU INTERSTITIAL ❑ SIR ❑ 9 WEEKKLY GA MANUAL ❑ 10 MOSTINLY TANK E] 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 ❑ 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 6 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE I.D:# COUNTY# JURISDICTION# FACILITY# TANK# _8� PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLI ON-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FO C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THEGROUND STORAGE TANK REGULATIONS FORM B (6-95)