COMPLIANCE INFO_1984-2002 - Laserfiche WebLink

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pCgouwC,s c0 STATE OF CALIFORNIA r STATE WATER RESOURCES CONTROL BOARD ;� g UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B •CSI IwOR H,r COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. (1 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS D ON SITE ONE ITEM El INTERIM PERMIT F--] 4 AMENDED PERMIT Rl TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Qu I K �"Lo P 12-q-- SS I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN ]]Ei% A. OWNER'S TANK I.D.# I Z�-.-3 B. MANUFACTURED BY: �XE S C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: l Q.z000 II.TANK ONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM a 80 EMPTY d1 PRODUCT ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL O 7 METHANOL ❑ lc MIDGRADE UNLEADED ❑ 5 JETFUEL E] 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 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 FVf I 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 ❑ 8 100% 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 KNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES—� NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP al/4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ga / 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL etc. SPILL CONTAINMENT TALLED(YEAR) OVERFILL EVENTION 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 0 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A 1 SINGLE WALL A V2 DOUBLE WALL A U 3 LINED TRENCH A 95 UNKNOWN A U 99 OTHER C. MATERIAL AND ABARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE( VC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION MECHANICAL UNE LEAK 2 UNE TIGHTNESS [:]3 CONTINUOUS INTERSTITIAL 4 ELECTRONIC UNE 5 AUTOMATIC PUMP 1 DETECTOR TESTING MONITORING ❑ LEAK DETECTOR ❑ SHUTDOWN ❑ 99 OTHER V.TANK LEAK DETECTION ANNUAL �F1 1 VISUAL CHECK ❑ 2 RECONCILIATION MANUAL INVENTORY ❑ 3 MONITORING VADOZE 4 AUTOMATGAUGING IC TANK E:] 5 MON TORINGGROUND WATER ❑ 6 TESTINGTANK 7 MONITORING INTERSTITIAL El8 SIR ❑ 9 WEEK LY MANUAL ❑10 MO TINLY TANK [_-] 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAY/YR�J/ 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 THIS FORM HAS BEEN COMPLETED UNDER PEN LTY F E URY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME JDATE (PRINTED a SIGNATURE) M`V e �G'� 11 ,rjCTJ (? LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.4 m PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE O �A 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 INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT 19FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THRGROUND ST RAGE TANK REGULATIONS FORM B (6-95) SY�'r `1�