COMPLIANCE INFO_1998-2006 - Laserfiche WebLink

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f k. STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD i =UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B tl COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY C 0SE"N SITE E ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ( . I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNER'S TANK 1.D.# B. MANUFACTURED BY: Tj_\ C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: IL TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C ❑ 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 1b PREMIUM UNLEADED E] 4 GASAHOL F--] 7 METHANOL I F—] 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT ❑ 1C MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ B 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 LINER E] 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 COMPATIBLEW/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED Ll 2 ALKYD LINING ❑ 3 EPDXY LINING O 4 PHENOLIC LINING LINING OR 5 GLASS LINING F'6 UNLINED ❑ 95 UNKNOyVN El 99 OTHER COATING 110 , IS LINING MATERIAL COMPATIBLE WITH 1001% METHANOL? YES_ NO_ D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION El5 CATHODIC PROTECTION 91 NONE 1'z}�) E:195 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL BiSPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTIO UIPMENT INSTALLED(YEAR) + C. DROP TUBE YES 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 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE ri CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELW/COATING A U 8 100% METHANOL COMPATIBLE WFFIP- PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER ❑ D. LEAK DETECTION / MECHANICAL LINE LEAK 2 UNE TIGHTNESS ❑3 CONTINUOUS INTERSTITIAL 4 ELECTRONIC UNE 5 AUTOMATIC PUMP . DETECTOR ❑ TESTING MOMTORING ❑ LEAK DETECTOR ❑ SHUTDOWN 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL RECONCILIATION INVENTORY ❑ 3 MONITORING ❑ 4 AUTOMATGAUGING IC TANK 5 MONITORINGGROUND ❑6 TESTINGTANK -' ❑ 7 MONITORING INTERSTITIAL ❑ 8 SIR A ❑ 9 NK GAUGINGAL ❑10 TM STINGY TANK ,415 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED.DATE LAST ED(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 PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME__ (PRINTED a SIGNATURE) 1 'k/S .�•.�!� ��t . / _ 4 ... Z2 y( LOCAL AGENCY USE ONLY 4 THE STATE\I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW CJ COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.4 m F-FT-1 1 1 1717W PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION UA goL 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 PULE THIS FORM WITH THE L �Y IMPLEMENTING THE R STORAGE TAN ONS FORM 8 (6-95) V�IYY IC,�Q{,y