COMPLIANCE INFO_1998-2006 - Laserfiche WebLink

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STATE OF CALIFORNIA ,r ti STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT,APPLICATION- FORM B -COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY F"ll 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: 0 �\P\2 E L U Q\ 1. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNER'S TANK 1.D.# B. MANUFACTURED BY: x Z— V�'\ X 5 C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS- GQ Ii.TANK CONTENTS IF A-1 IS MARKED,COIu1PLETEITEM C. A ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C ,1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ ❑ 1 PRODUCT F-1lbPREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOI 2 PETROLEUM 80 EMPTY ❑ tc 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.#: 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 (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 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE P ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,etc. SPILL CONTAINM STALLED(YEAR) OVERFIL'4 PREVENTION_EQUIPMENT INSTALLED(YEAR) DROP TUBE YES NO STRIKER PLATE YES ` NO DISPENSER CONTAINMENT YES- NO IV.PIPING INFORMATION CIRCLE A IF ABOVE ROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLEPIPING 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-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 MECHANICAL UNE LEAK ❑2 LINE TIGHTNESS /`~ 3 CONTINUOUS INTERSTITIAL ❑4 ELECTRONIC UNE 5 AUTOMATIC PUMP❑ 99 OTHER DETECTOR TESTING MONITORING LEAK DETECTOR SHUTDOWN - V.TANK LEAK DETECTION yr❑-� 1 VISUAL CHECK ❑ 2 RECONCILIATIONMANUAL INVENTORY F—] 3 MONIITORING VAOZE4 GAUGING AUTOMATIC TANK ❑5 MON TORINGGROUND WATER ❑6 TESTINGTANK 7 CONTINUMONITORU INTERSTITIAL ❑ 8 SIR ❑ 9 TANK LY MANUAL ❑10 MO TINLY TANK ❑ 95 UNKNOWN ❑99 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 I 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 1( -- (�(�/ r /' j� DATE' (PRINTED 6 SIGNATURE)- 1 v i t • _ i {" F V� o wNt I` ' (� LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW . VV mos COUNTY# JURISDICTION# FACILITY It _ TANK# STATE I.D.4 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 IjfGROUND STORAGE TANK REGULATIONS FORM B (6-95)