COMPLIANCE INFO_1997-2002 - Laserfiche WebLink

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s STATE OF CALIFORNIA za,ncc .�"` cv STATE WATER RESOURCES CONTROL BOARD + UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B COMPLETE A SEPARATE FORM FOR.EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT t 5 CHANGE OF INFORMATION 7 PERMANENTLY C WSigrON SI E ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOV)26 �j DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 1 U S Llo IF P,C\L\7 ` tj I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK 1.D.# LA b\ Y\1�b 14 �L\ B. MANUFACTURED BY: 4� �\v\\ C. DATE INSTALLED(MO/DAYNEAR) L\�\/"m V V\\ D.TANK CAPACITY IN GALLONS: S UUO V IL TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. ,k ❑. 1 MOTOR VEHICLE FUEL ❑ 4 OIL S. C. ❑ 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ib PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL El 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT �Rlc MIDCRADE UNLEADED ❑ ❑3 CHEMICALPRODUCT ❑ 95 UNKNOWN E] 2 WASTE 5 JET FUEL 8 M85 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(At)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 ❑ 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 ❑ 8 100% METHANOL COMPATIBLEW/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING Fn 6 UNLINED ❑ 95 UNKNOWN ❑ 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 E.SPILL AND OVERFILL etSPILL 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 311D 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A-.0) 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 U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)&1 1f';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 ❑1 MECHAMCAL LINE LEAK ❑2 UNE TIGHTNESS ❑3 CONTINUOUS INTERSTITIAL ©4 ELECTRONIC LINE ❑5 AUTOMATIC PUMP ❑ 99 OTHER DETECTOR TESTING MON ITORM LEAK DETECTOR SHUTDOWN V.TANK LEAK DETECTION pp� ❑ NUAL 1 VISUAL CHECK L—J 2 RECONCILIATIONMANUAL RY ❑ 3 VAOZEMONIITORING ❑ 4 GAUGING AUTOMATIC TANK ❑ 5 MONITORING GROUNDTER 6 TESTINGTANK ❑ 7 MON TOR NG INTERSTITIAL ❑ 8 SIR ❑ 8 WEEKLY MANUAL ❑10 MONTHLY TANK ❑ 95 UNKNOWN E] 99 OTHER TANK GAUGING TESTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAY/YR) F2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 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 ' (� _ /�^ i10 LOCAL AGENCY USE ONLY THE STATELII.`D.NUMBER IS COMPOSED OF THE FOUR NUMBERSBELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.4 m 0 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLIN•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOMUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PIWLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE w GROUND STORAGE TANK REGULATIONS FORMS (6.95)