COMPLIANCE INFO_1997-1999 - Laserfiche WebLink

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�soun°r;y i. STATE OF CALIFORNIA A cO STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B •CSI IIORM\� COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY a 1 NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ON SITE ONE ITEM F-1 2 INTERIM PERMIT F-1 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE E] 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ZQ Q L I_/{ TE<. I. TANK DESCRIPPJK*- COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: Q O II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A. a 1 MOTOR VEHICLE FUEL r7 4 OIL g. C 1a REGULAR UNLEADED O 3 DIESEL [::] 6 AVIATION GAS 71 2 PETROLEUM 80 EMPTY 1 PRODUCT 1b PREMIUM UNLEADED [::] 4 GASAHOL [�] 7 METHANOL 1c MIDGRADE UNLEADED F-] 5 JET FUEL F-1 8 M85 3 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE 0 2 LEADED Ej 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 a 1 DOUBLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER O 5 INTERNAL BLADDER SYSTEM [:] 95 UNKNOWN SYSTEM 2 SINGLE WALL O 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK 1 BARE STEEL 2 STAINLESS STEEL a 3 FIBERGLASS E] 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL F-] 5 CONCRETE F-1 6 POLYVINYL CHLORI E:] 7 ALUMINUM E] 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) a 9 BRONZE O 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER C.INTERIOR D 1 RUBBER LINED 1:1 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING LINING OR 5 GLASS LINING F-] 6 UNLINED 95 UNKNOWN 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 1001/6 METHANOL? YES— NO— D.EXTERIOR 1 POLYETHYLENE WRAP D 2 COATING 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION D 5 CATHODIC PROTECTION E::] 91 NONE 95 UNKNOWN � 99 OTHER E.SPILL AND OVERFILL,CtC. 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 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)5 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 STEELW/COATING A U 8 100% METHANOL COMPATIBLEW/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 5 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 MECHANICAL LINE LEAK F-12 UNE TIGHTNESS ❑3 CONTINUOUS INTERSTITIAL 4 ELECTRONIC LINE [:]5 AUTOMATIC PUMP 99 OTHER DETECTOR TESTING MONITORING LEAK DETECTOR SHUTDOWN V.TANK LEAK DETECTION 1 VISUAL CHECK 2 MANUAL RECONCILIATION ORY 3 VADOZEMONITORING 4 GAUGINAUTOMATG MONITORING TANK 5 MONTORINGGROUND TER 0 6 TESTINGANNUALTANK a 7 MONITOR CONTINUOUS 8 SIR 9 WEEK LY MANUAL a 10 MO TINLY TANK 95 UNKNOWN 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LA T U D( /DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES 0 NO 0 Z SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HA BEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTED b SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# 2— STATE I.D.4 F3[-ql = Q 4 6 Z ! </ Z ,6To PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE I` �1:1 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 INSTALLA 0 S.THIS FORM SHOULD BE IED BY//A PLOT PLAN. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM 8 (6-95) l 1