COMPLIANCE INFO_1998-2006 - Laserfiche WebLink

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• . SpUACf3 STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD i g UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B r - . , COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION Z1, 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: C /\a t L (U I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN p' I�, A OWNER'S TANK I.D.# B. MANUFACTURED BY: L\t V!',t V t)JA` C v C. DATE INSTALLED(MO/DAY/YEAR) L\ry Y i\>U \N D. TANK CAPACITY IN GALLONS: boo II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A ❑•1 MOTOR VEHICLE FUEL ❑ 4 OIL C to REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATIONGAS ❑ E] lb PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 1C MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOM D. IF(Ai)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 92 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK I 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 En 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑*95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL etSPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) OVERFILL, 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 AUO 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 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 DETECTION1 MICHAMGL LME LEAK 2 UNE TIGHTNESS 3 CONTINUOUS INTERSTITIAL 4 ELECTRONIC LINE 5 AUTOMATIC PUMP ❑ DETECTOR ❑ TESTING MONITORING © LEAK DETECTOR ❑ SHUTDOWN ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 MANUAL INVENTORY ❑ 3 VADOZE ❑ 4 AUTOMATIC TANK E::] 5 GROUND WATER 6 ANNUAL TANK RECONCILIATION MONITORING GAUGING MONITORING TESTING 7 MON TOR U INTERSTITIAL ❑ 8 SIR ❑ 9 WEETANKLY MANUAL ❑10 MONTHLY TANK ❑ 95 UNKNOWN F–]99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAY/YR) F2.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,1S TRUE AND CORRECT TANK OWNER'S NA , (PRINTED S SIGNATURE) �� i >� � t '}✓''� V LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS CLLLL��OMPOSED OF THE FOUR NUMBERS BELOW COUNTY II JURISDICTION# FACILITY# TANK# STATE I.D:# m 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 PULE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE I&GROUND STORAGE TANK REGULATIONS FORMS (6-95)