COMPLIANCE INFO_1997-2002 - Laserfiche WebLink

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. -,. -..< .... w _. ...,:.. ...-n.ic. r :.�mm .P' ...:-. `.��.,Y«s` 3�'&=4 _ -s'npb^i.rvx....-3j.s. ...q....: y�g..4•,rC+^,smr w. ,re.+_ _ .— „ -.. '�bOUAC!].0 STATE OF CALIFORNIA +� STATE WATER RESOURCES CONTROL BOARD 3 g UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B p� *� C'+L�RMS► COMPLETE A SEPARATE FORM FOREACH TANK SYSTEM. so MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION PERMANENTL ON S ONE ITEM F__] 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE TANK RE;YD DBA OR FACILITY NAME WHERE TANK IS INSTALLED: L\7 � I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# ) B. MANUFACTURED BY: m C. DATE INSTALLED(MO/DAYNEAR) D. TANKCAPACITY IN GALLONS: 60 DOD II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A. ❑rv1 MOTOR VEHICLE FUEL ❑ 4 OIL B, C to REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATIONGAS 'UNLEADED ❑ 4 GASAHOL E:] 7 METHANOL ❑ 2 PETROLEUM ❑ 80 EMPTY 1b PREMIUM �1 PRODUCT ❑ lc MIDGRADE UNLEADED.❑ 5 JET FUEL E] 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE 8 M85 IBE IN ITEM D.BELOPn 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 1 DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN A. TYPE OF ❑❑ " ❑ ❑ SYSTEM- I r`• 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑r' 4 STEEL CLAD W1 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 2 ALKYD LINING ❑ 3 EPDXY LINING ❑` 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING HIS 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 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 ROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A'U' 1 SUCTION A 41A 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 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)A'V-"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 Ej 1 MECHANICAL UNE LEAK2 UNE TIGHTNESS 3 CONTINUOUS INTERSTITIAL DETECTOR ❑ TESTING ❑ MONITORING " ❑4 ELECTRONIC UNE 5 AUTOMATIC PUMP MM DETECTOR ❑ SHUTDOWN [D99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 MANUAL INVENTORY ❑ 3 VADOZE ❑ 4 AUTOMATIC TANK ❑ 5 GROUND WATER �6 ANNUALTANK RECONCILIATION MONITORING GAUGING MONITORING TESTING ❑ 7 CONTINUOUS MONITORING INTERSTITIAL ❑ 6 SIR ❑ 9 ANEK GAUGANGAL ❑10 MONTHLY TANK ❑ 95 UNKNOWN ❑S OTHER TESTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) L ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3,WAS TANK FILLED WITH YES E] No F-] SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OFFK OWNER'S NAM — P�E-RRJ'UR/Y,}AND TO THE BEST OF MY KNOWLEDGE,1S TRUE ANlD\CORRECT (PRIINTED&SIGNATURE) E _, 1 1/1 �(" �a _ /f Do ATE I 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 [ p PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE " THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLIC N-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FO ^MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PULE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE IWGROUND STORAGE TANK REGULATIONS FORM B (6.95)