COMPLIANCE INFO_2002-2010 - Laserfiche WebLink

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a, ±x . :�� ..wG,.,�� .ae.'t ;. ;. •. �i.,�t �.,�*�•-.�q.�. g .,�:q r,.r'; �. -¢ 8 §"'��(�:'z A ... fit. .� .• C7 STATE OFCALIFORNIA �. STATE WATER RESOURCES CONTROL BOARD W� , UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM l MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT 4 AME3 0 P R`M�IT, ❑ 6 TEMPORARY TANK CLOSURE ❑ 6 TANK REMOVED l DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 0 YZ I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.4 B. MANUFACTURED BY: S C. DATE INSTALLED(MOlDAY/YEAR) c. L 6 D. TANK CAPACITY IN GALLONS: ' ILTANKCONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. 1a REGULAR 3 DIESEL � p ❑# 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. UNLEADED ❑ ❑ 6 AVIATKNJ GAS 4 GASAHOL ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT ❑ 1b PREMIUM ❑ 7 METHANOL ,y UNLEADED ❑ 5 JET FUEL s ❑ 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.&8: IIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,8.AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF � 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM F7 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS © 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL., ❑ 6 .POL'YVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP ..... ❑ 5 CONCRETE (PrimaiTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED - 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LININGt IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL 7 YES NO D.CORROSION 711 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP " 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER K E,SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) - IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION ASU 2 PRESSURE A U 3 GRAVITY 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 AU 99 OTHER q 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 W/fi AT1NG „ U B 100% METHANOL COMPATIBLE WlFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER ode 3 INTERSTITIAL D. LEAK DETECTION st AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING L MONROR1NG ❑99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ ,,2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL? S ❑ NO THIS FORM,HAS BEEN CO PL TE NDER•PENAiTY OG PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAOE DA (PRINTED 8 SIGNAT REj z*. (�G+ LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# -. TANK# STATE I.D.# m X 1 3 ' 1111 6 lql111151 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE y THIS FORM MUST BE AC Dh EO BY A PEIIMIT APPLICATION•FORM A,UNLESS A CURNT FORM A HAS BEEN FILED., FILE THIS FORM WIN AL AGENCY IMPLEMENTING THE UNDERGROUND SE TANK REGULATIONS FORM B (12.91) r