COMPLIANCE INFO_1998-2006 - Laserfiche WebLink

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•`gOU1.C.9 C STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B •CSI IRORM\r COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE. ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.• B. MANUFACTURED BY: _ C. DATE INSTALLED(MO/DAYNEAR) c D. TANK CAPACITY IN GALLONS: I CJ l) 11.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 ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ 80 EMPTY � 1 PRODUCT ❑ lc MIDGRADE UNLEADED E] 5 JET FUEL F-18 M85 ❑ 3 CHEMICAL PRODUCT ❑ 85 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOVO 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 ❑ 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 COMPATIBLE W/FRP (PdMary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER 1 RUBBER LINED 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING C.INTERIOR ❑ ❑ ❑ LINING OR ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100°/6 METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING CORROSION ® 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL et , SPILL CONTAINME I TALLED(YEAR) OVERFI P ENTION EQUIPMENT INSTALLED(YEAR) \ cDROP TUBE YES NO STRIKER PLATE YES NO DISPENSER CONTAINMEN YES NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION AT 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL Al) 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 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 [—]l MICIMCIL LINE LEAK 2 UNE TIGHTNESS 3 CONTINUOUS WFAM ul 4 ELECTROMC UNE 5 AUTOMATIC PUMP ❑ DETECTOR ❑ TESTING MONITORING CEldf DETECTOR SHUTDOWN 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 GROUND WANUAL RRECONCILIATIONUAL INVENTORY ❑ 3 MONITORING VADOZElz 4 GAUGING AUTOMATIC TANK ❑5 MON TORINGTER ❑8 TESTINGTANK 7 MON TOR U INTERSTITIAL ❑ 8 SIR E:] 9 TANK GAUGINGAL ❑10 MOSNTHLY TING 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 ❑ NO❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL Z 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 COMPOED OF THE FOUR NUMBERS BELOW STATE LD:# COUNTY# JURISDICTION# FACILITY# _ 3 u PERMIT NUMBER PERMIT APPROVED BY/DATE PE IT EXPIRATION DATE q-1_1d wl THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORMA,UNLESS A CURRENT FORMA HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PULE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE ROUND STORAGE TANK REGULATIONS FORM B (6.95)