COMPLIANCE INFO_1986-1996 - Laserfiche WebLink

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°yes Act STATE OF CALIFORNIA Ap" STATE WATER RESOURCES CONTROL BOARD W m UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B •C'+t,ROM N,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 F-] 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: L36 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D. B. MANUFACTURED BY: -119 C. DATE INSTALLED(MO/DAYNEAR) z 2-6-1D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A Q 1 MOTOR VEHICLE FUEL IN_4 OIL B. C. ❑ 1a REGULAR UNLEADED 0 3 DIESEL Q 6 AVIATIONGAS a 2 PETROLEUM a 80 EMPTY ❑ 1 PRODUCT Q 1b PREMIUM UNLEADED O 4 GASAHOL Q 7 METHANOL ❑ lc MIDGRADE UNLEADED j 5 JETFUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN Ppj 2 WASTE ❑ 2 LEADED 99 OTHER(DESCRIBE IN ITEM D.BELOM D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED ' r 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 NL2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 1001/6 METHANOL COMPATIBLE WIFRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING F-1 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ® 5 GLASS LINING UNLINED ❑ 95 UNKNOWN 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP F_� 2 COATING F-] 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION z 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL @tSPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) + C. 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 !62 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION IT 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 622 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 Q 1 MECHANICAL UNE LEAK xznh UNE TIGHTNESS 3 CONTINUOUS INTERSTITIAL I'7 4 ELECTRONIC UNE Q 5 AUTOMATIC PUMP O 99 OTHER DETECTOR TESTING MOMTORING L-1 tEAK DETECTOR SHUTDOWN V.TANK LEAK DETECTION ® 9 VISUAL CHECK 2 MANUAL INVENTRECO CILIIATIONORY 3 MOONIITORING ❑OZE4 GAUL NGAUTOMATIC TANK ❑ 5 MON TORINGGROUND WATE 6 STINGTANK ® 7 CONTINUOUS MONITORING INTERSTITIAL 8 SIR ❑ TANUALI ENK GAUGING TESTING❑10 TM STING TANK E:] 95 UNKNOWN ❑ TE99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LA?l USED(M AY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES F_� NO❑ SUBSTANCE REMAINING GALLONS 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 DATE (PRINTED 6 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D:# `®® PERMIT NUMBER OERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE ll q6 THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FO INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT P LE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THEGROUND STORAGE TANK REGULATIONS FORM B (6.95) qw v FOR0034B&R7