COMPLIANCE INFO_1985-1998 - Laserfiche WebLink

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tgouaces STATE OF CALIFORNIA ...... A Q'STATE WATER RESOURCES CONTROL BOARD 0 UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY F-1 1 NEW PERMIT F-] 3 RENEWAL PERMIT F-1 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT F-1 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE F-] 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 93 C:' 115 - j:,P'-rrT-,c/A�A 4A�, 4,9>,j= I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A- OWNER'S TANK 1.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MC/DAYNEAR) D. TANK CAPACITY IN GALLONS: 11.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A. F-W MOTOR VEHICLE FUEL F-] 4 OIL B. C. [--] IS REGULAR UNLEADED3 DIESEL ❑ 6 AVIATION GAS 2 PETROLEUM El 80 EMPTY I PRODUCT F-1 lb PREMIUM UNLEADED 4 GASAHOL F-] 7 METHANOL 1:1 is MIDGRADE UNLEADED 5 JET FUEL F-] 8 M85 ❑ 3 CHEMICAL PRODUCT 1:1 95 UNKNOWN E�2 WASTE 0 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF ❑ I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM 95 UNKNOWN SYSTEM El 2 SINGLE WALL 0 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL F-1 2 STAINLESS STEEL F-] 3 FIBERGLASS F7 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL F-] 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE F--] 7 ALUMINUM E 8 100% METHANOL COMPATIBLEW/FRP (Primary Tank) ❑ 9 BRONZE [::] 10 GALVANIZED STEEL 5695 UNKNOWN E] 99 OTHER _ C.INTERIOR ❑ I RUBBER LINED F-1 2 ALKYD LINING n 3 EPDXY LINING F-] 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING F-1 6 UNLINED E fl UNKNOWN F-] 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 1001/6 METHANOL? Ys_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING F-] 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION [::] 91 NONE �Y?5 UNKNOWN E] 99 OTHER E.SPILL AND OVERFILL,etc. SPILL CONTAINMENT INSTALLED(YEAR)— 'OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) 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 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 95 UNKNOWN A U 99 OTHER C. KA,-ERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE C% IOSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PRO;ECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION rV95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 0 1 MECHANICAL LINE LEAK Ej 2 LINE TIGHTNESS F--j 3 CONTINUOUS INTERSTITIAL Ej 4 ELECTRONIC LINE r--1 5 AUTOMATIC PUMP ❑ 99 OTHER DETECTOR TESTING L--J MONITORING LEAK DETECTOR L---J SHUTDOWN V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 MANUAL 3 INVENTE] VADOZE Ej 4 AUTOMATF-] GROUND,WATER NUAL RECONCILIATIONORY MONITORING ❑ GAUGING IC TANK 5 MONITOR NG AN 09 TESTINGTANK ❑ 7 MONITCONTINUOUS INTERSTITIAL K8 SIR ❑ 9 WEEKLY MANUAL Ej TESTING 10 MONTHLY TANK [-] 95 UNKNOWN 99 OTHER ORING TANK GAUGING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST UrED(Mr/DA Y5). 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING INERT MATERIAL. YES I f f GALLONS I THIS FORM NAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTED&SIGNATURE) I LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE I.D.4 COUNTY# JURISDICTION# FACILITY# TANK# 1-1 19 1(- 1-711 d I PERMIT NUMBER PbMIT APPROVED BY/DATE PERMIT EXPIRATION DATE 1 12,W20 THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICAUON-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. F MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PIWILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THEWFIGROUND STORAGE TANK REGULATIONS FORM B (6-95)