COMPLIANCE INFO_1998-2006 - Laserfiche WebLink

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STATE OF CALIFORNIA '.•". STATE WATER RESOURCES CONTROL BOARD i� c UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED..ON qITC ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE (]gam 8 TANK REMOVED It DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 1710 (_, 7 Ze 7 -75%� I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN A OWNER'S TANK 1.D.fi B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAY/YEAR) O y\n\ L, D. TANK CAPACITY IN GALLONS: .. II.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 E-1 2 PETROLEUM El 80 EMPTY E:] lb PREMIUM UNLEADED E] 4 GASAHOL ❑ 7 METHANOL ❑ 1 PRODUCT F-1tc MIDGRADE UNLEADEDH-99 5 JET FUEL ❑ B M85 ❑ 3 CHEMICAL PRODUCT E] 95 UNKNOWN 2 WASTE E] 2 LEADED OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED ��` =^` Y u\L C.A.S.re 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 1DOUBLE WALL F--] 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM 92 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 COMPATIBLE W/FRP (Primary 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 r, 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES— NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP2 COATING F-13 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION E] 5 CATHODIC PROTECTION R 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 ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A x,U-23 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 U 1 BARE STEEL A 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 STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 MECHAMCAL LINE LEAK 2 UNE TIGHTNESS 3 CONTINUOUS INTERSTITIAL 4 ELECTRONIC LINE 5 Auraw►nC PUMP DETECTOR TESTING MONTORING © LEAK DETECTOR NVOY OWN ❑.99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUALIRECONCILIATION MONITORING ❑ 3 MODOZENIITORING ❑ 4 AUTOMATGAUGING IC TANK ❑5 GROUND MONITORING TER ❑6 TETANK STING ❑ 7 CONMON INUOU INTERSTITIAL E] 8 SIR E:] 9 WE K LY MANUAL ❑10 TEMONTHLY STING TANK ❑ 95 UNKNOWN ❑99 OTHER ORINVI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED /YR) 2.ESTIMATED QUANTITY OF /� 3.WAS TANK FILLED WITH SUBSTANCE REMAINING C�GALLONS INERT MATERIAL? YES ❑ NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME _ 1 DATE (PRINTED 6 SIGNATURE) , y �/� \ �� '�-^ / � 1-_✓'. ' (� l J LOCAL AGENCY USE ONLYt THE STATE I.D.NUMBER IS COMPO/SED OF THE FOUR NUMBERS BELOW —7 COUNTY# JURISDICTION# FACILITY# TANK# STATE LD:# PERMIT NUMBER 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 SHOULD BE ACCOMPANIED BY A PLOT PLAN. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE U GROUND STORAGE TANK REEGfULA FORM B (6-95) 3