COMPLIANCE INFO_1991-2004 - Laserfiche WebLink

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gou STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD i Ab .0 UNDERGROUND STORAGE TANK PERMIT APPLICATION FORM B Ti .0 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM F-] 2 INTERIM PERMIT F__j 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 4:::!!+4E=-j go,:� i5-r,4�1-104 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK 1.D.# B. MANUFACTURED BY: -s C. DATE INSTALLED(MOIDAYNEAR) D. TANK CAPACITY IN GALLONS: 11.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. 3 DIESEL r__j 6 AVIATION GAS A. [N I MOTOR VEHICLE FUEL ❑ 4 OIL B. C. to REGULAR UNLEADED ❑ 2 PETROLEUM ❑ 80 EMPTY I PRODUCT ❑ lb PREMIUM UNLEADED E] 4 GASAHOL F-17 METHANOL 19 le MIDGRADE UNLEADED ❑ 5 JET FUEL F-1 8 M85 ❑ 3 CHEMICAL PRODUCT E:] 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.#: 9 Ill. 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 F7 3 SINGLE WALL WITH EXTERIOR LINER F__1 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ I BARE STEEL ❑ 2 STAINLESS STEEL Eg 3 FIBERGLASS ❑ 4 STEEL CLAD W1 FIBERGLASS REINFORCED PLASTIC MATERIAL F-1 5 CONCRETE F__j 6 POLYVINYL CHLORIDE F-1 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) E] 9 BRONZE E] 10 GALVANIZED STEEL 0 95 UNKNOWN Ej 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING F__j 3 EPDXY LINING 0 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING K 6 UNLINED 0 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— N D.EXTERIOR ❑ 1 POLYETHYLENE WRAP E] 2 COATING E] 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION 0 5 CATHODIC PROTECTION 0 91 NONE aq-* [:]95 UNKNOWN ❑ 99 OTHER SPILL CONTAINMENT INSTALLED(YEAR) I I I f-- OVERFILL FREVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,etC- DROP TUBE YES_2S,_ NO_ STRIKER PLATE YES-_7—N NO— DISPENSER CONTAINMENT YES-',)E NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A 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 U 95 UNKNOWN A U 99 OTHER U, C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)Ado- FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL WICOATING A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 0 1 MECHANICAL UNE LEAK E]2 LINE TMMW 3 Comwjous NTERSTITIAL M 4 ELECTRONIC UNE 5 AUTOMATIC PUMP DETECTORTESTWO MONTORING LEAK DETECTOR SHUTDOWN ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL INVENTORY ❑ 3 VADOZE 4 AUTOMATIC TANK ❑5 GROUND WATER F__] 6 ANNUAL TANK RECONCILIATION MONITORING GAUGING MONITORING TESTING TANK CONTINUOUS MONITORING TANINTERSTITIAL ❑ 8 SIR E] 9 WEEK KLY MANUNGAL _.LESTING 10 MONTHLY TANK ❑ 95 UNKNOWN ❑99 OTHER GAUGI VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH ❑ I SUBSTANCE REMAINING—GALLONS INERT MATERIAL? YES E:] NO 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&SIGNATURE) a I LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED g(F4E FOUR NUMBERS BELOW COUNTY# JURISDICTION III FACILITY III TANK# STATE I.D.4 m FT7171 I I I I I I I I I I 1 11 1 PERMIT NUMBER PERMIT APPROVED BY/DATE Li PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APP TION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED.10M C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLO�,.- FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING TIIIIIIIIIIIIIIIPERGROUND STORAGE TANK REGULATIONS FORM B (6-95)