COMPLIANCE INFO_1984-2002 - Laserfiche WebLink

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Pt,oURC�s STATE OF CALIFORNIA .P o r STATE WATER RESOURCES CONTROL BOARD ; o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT � h CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT I I 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED Dl DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Qul(` 5ToP 12A-- S� 1. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# 1-2-4— 1 B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) 1'7 0.5 D. TANK CAPACITY IN GALLONS: g OO C) �J 11.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C Wa REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATIONGAS A ❑ 2 PETROLEUM ❑ 80 EMPTY � PRODUCT b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 1c MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOM 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 21 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 ❑ 6 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING LINING OR F—] 5 GLASS LINING 6 UNLINED ❑ 95 (INKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ! ❑ 95 UNKNOWN ❑ 99 OTHER f E.SPILL AND OVERFILL,BtC. SPILL CONTAINMENT I ALLED(YEAR) OVERFILL P VENTION EQUIPMENT INSTALLED(YEAR) wip flu 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 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A 2 DOUBLE WALL A U 3 LINED TRENCH A 695 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 /COATING A 8 100% METHANOL COMPATIB EW/FRP PROTECTION A U GALVANIZED STEEL/A U 10 CATHODIC PROTECTION A UNKNOWN A 9 OTHER D. LEAK DETECTION 1 MECHANICAL UNE LEAK 2 LINE TIGHTNESS ❑3 CONTINUOUS INTERSTITIAL O ELECTRONIC LINE ❑5 AUTOMATIC PUMP 99 OTHER DETECTOR TESTING MONITORING LEAK DETECTOR SHUTDOWN V.TANK LEAK DETECTION W❑ ANNUALVISUAL CHECK El2 MANUAL RECONCILIIATIIONVENTORY E] 3 MONITORING VADOZE E�f4 GAUGING AUTOMATIC TANK ❑ 5 MON TORINGGROUND WATER ❑ 6 TESTING TANK 7 MONITORCONTINUOUS INTERSTITIAL ❑ 8 SIR E] 9 WEEK LY MANUAL E]10 MO TINLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/D2.ES, E ESTIMATED QUANTITY OF GALLONS 3.WAS FILLED WWII?H S THIS FORM HAS BEEN COMPLETED UNDER PEN TY O ER RY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME DAT9\ (PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I. . POSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY#1044frl TANK# STATE I.D.# m11 1414-1A 0 111 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLI ON-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. F C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING TH GROUND STORAGE TANK REGULATIONS FORM B 6-95