COMPLIANCE INFO_1998 REMOVAL AND INSTALL

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'�sOvweea STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD �+y,R• v UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B •C/1110RN'- COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS ON SITE ONE ITEM ❑ 2 INTERIM PERMIT Rr4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED I DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.N I t t jq:�? – i B. MANUFACTURED BY: x a� C. DATE INSTALLED(MO/DAY/YEAR) p t S D. TANK CAPACITY IN GALLONS: �-+- II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A. 0 ' MOTOR VEHICLE FUEL ❑ 4 OIL B. C to REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑❑ ib PREMIUM UNLEADED ❑ 4 GASAHOL 7 METHANOL 2 PETROLEUM ❑ 80 EMPTY PRODUCT ❑ is 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.B 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 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 Ce3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Pdmary 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 D?r99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR CORROSION � 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE oof 00.4 ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL etSPILL CONTAINMENT INWLLED(YEAR) OVERFILL L3REVENTION EQUIPMENT INSTALLED(YEAR) + c. DROP TUBE YES NO TRIKER PLATE YES A-_ NO DISPENSER CONTAINMENT! NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION M2 PRESSURE 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 A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A 40 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 1 MECHANICAL LINE LEAK V2 UNE TIGHTNESSCOITONUOUS INTERSTITIAL ED4 ELECTRONIC UNE 5 AUTOMATIC PUMP ❑ 99 OTHER TESTING MONTORINO LEAK DETECTOR SHUTDOWN V.TANK LEAK DETECTION ❑ 1 ISUAL CHECK ❑ 2 RRE ONCILIATIONUAL ORY ❑ 3 MAONNIITORING ❑ 4 GAUGING AUTOMATIC TANK ❑5 GROUND MONITORING TER 8 ANNUAL TESTING 7 CON TOR U INTERSTITIAL ❑ 8 Sip ❑ 9 TANK LY MAGAUGINUAL ❑10 MO TINLY TANK E] 95 UNKNOWN F__199 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 YES ❑ NO❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PffiL4 TY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME � �e-rz `� DA/TyE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.4 1 ,21-311 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE /l THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLI •FORMA,UNLESS A CURRENT FORMA HAS BEEN FILED. FOUST BE COMPLETED FOR INSTALLATIONS.TH FORM SHOULD BE ACCOMPANIED BY A PLOT PLVLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE WROUND STORAGE TANK REGULATIONS FORM B (6.95)