COMPLIANCE INFO_1995-1999 - Laserfiche WebLink

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STATE OF CALIFORNIA �� } STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B 1 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL.PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO 0 SI ONE REM 2 INTERIM PERMIT F74 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: RI cAle I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN EA. D. TANK CAPACITY IN GALLONS: �(7 f o�OWNERS TANK I.D.M 3 B. MANUFACTURED BY: C. DATE INSTALLED(M(ypAY/YEAR) 'L, (�j / C� II.TANK CONTENTS IF A•1 IS MARKED,COMPLETE ITEM C. to REGULAR UNLEADEDa 3 DIESEL ❑ 8 AVIATION GAS A 1 MOTOR VEHICLE KIEL ❑ 4 OIL & C. ❑ lb PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ 80 EMPTY Ql 1 PRODUCT ❑ 1c MIDGRADE UNLEADED5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED El 98 OTHER(DESCRIBE 1N ITEM D.BELOW) 0. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.AS.#: ILL TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C.AND ALL THAT APPLIES IN BOX 0 AND E IFI I DOUBLE WALL F-13 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM F7 95 UNKNOWN A. TYPE OF IGS ❑ ❑ 99 OTHER SYSTEM ❑ 2 SINGLE WALL 4 SINGLE WALL IN A VAULT 1 BARE STEEL r72 STAINLESS STEEL 5K 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WlFRP (primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING: ❑ 4 PHENOLIC LINING C.INTERIOR 8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING OR ❑ 5 GLASS LINING COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION91 NONE ❑95 UNKNOWN F799 OTHER PROTECTION ❑ s CATHODIC PROTECTION ❑ SPILLCONTAINMENT INSTAUJ:D(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E SPILL AND OVERFILL.eta DROP TUBE YES--"_ NO STRIKER PV TE YES �� NO DISPENSER CONTAINMENT YF� 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 U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 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@ 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 8 CONCRETE A U 7 STEEL W/COATING A U B 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN p� A U 99 OTHER 1 IEd1ANGL ANE LEAK 2 TESTINf 3 iCll16 N1'En5Tii1A1' ❑a t C DETECTORlU1E 1LY 5 gq)ippiniltCi PLaP ❑ 99 OTHER 0. LEAK DETECTION ❑ DETEcroR ❑ V.TANK LEAK DETECTION 1 VISUAL CHECK ❑ 2 MANUAL INVENTORY ❑ 3 VADOZE ❑ a AUTOMATIC TANK ❑5 GROUND WATER ❑8 T�ESTU'INGTANK ❑ RECONCILIATION MONITORING GAUGING MONITORING 7 CONTINUOUS INTERSTITIAL ❑ 8 SIR ❑ 9 TANK GAUGING ❑10 TESTING TANK ❑ 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLosum IN-PLACE) N ,bf 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑=NO= 1.ESTIMATED DATE LAST USED(MO/DAY/YR) SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UN,pDEyR�PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, 1S TRUE AND CORRECT TANK 011 MS NTE AME �{1 v D�C-1-0 l� (PRINTED 6 SH3NATLNIET / �Y LOCAL AGENCY USE ONLY THE STATE I.O.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY#372 b TANK#GCS STATE LD:# PERMIT EXPIRATION DATE I PERMIT NUMBER PERMIT APPROVED SY/DATEHAS BEEN FILED. .� THIS FORM MUST SE ACCOMPANIED BY A PERMIT APPUC^TIO�N-FOR FORM UN ESS TME LOC AGENCY WPLEMENTING THE FORM"SRGROUND STORAGE TANK REGULATIONED FOR S S.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT P�, . FORMS (&95)