COMPLIANCE INFO_1996-2008 - Laserfiche WebLink

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' STATE OF CALIFORNIA Ar '• °�r STATE WATER RESOURCES CONTROL BOARD a g UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B •01l IIOP N'' COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 1-<A Al )(OAI I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN f � A. OWNER'S TANK I.D.# B. MANUFACTURED BY: ` WID o..✓&7NIVAl ,17— C. DATE INSTALLED(MO/DAYNEAR) �'. f sj r � � D. TANK CAPACITY IN GAJLLONS: 4 Gav II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. ❑ ❑o REGULAR UNLEADED 3 DIESEL 6 AVIATION GAS A. ❑q 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. t ❑ a ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL O 7 METHANOL 2 PETROLEUM ❑ 80 EMPTY PRODUCT ❑ 1c MIDGRADE UNLEADED ❑ 5 JET FUEL � 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 ❑"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 E28 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 p LINING OR ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN E99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 1009/6 METHANOL? YES NO— D.EXTERIOR CORROSION El POLYETHYLENE WRAP F-] 2 COATING 3 VINYL WRAP Ln 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL CtC. 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 GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A(U)2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL 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 U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A8 100% METHANOL COMPATIBLEW/FRP PROTECTION A U 9 GALVANIZED STEEL .A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION1 MECHANICAL LINE LEAK 2 UNE TIGHTNESS 3 CONTINUOUS INTERSTITIAL 4 ELECTRONIC UNE 5 AUTOMATIC PUMP ❑ DETECTOR ❑ TESTING ❑ MONITORING ❑ 11AK DETECTOR ❑ SHUTDOWN ❑ 99 OTHER V.TANK LEAK DETECTION MANUAL INVENTANNUAL F-1 1 VISUAL CHECK ❑ 2 RECONCILIATIONORY ❑ 3 MONITORING VADOZE ❑ 4 GAUL NGAUTOMATIC TANK ❑ 5 MON TORINGGROUND WATER ❑6 TESTINGTANK `- 7 MONITOR U CONTINUS INTERSTITIAL E] 8 SIR ❑ 9 WEEK LY MANUAL ❑10 TMONTHLY ESTING TANK ❑ 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) AJ 44 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO ❑ SUBSTANCE REMAINING GALLONS I INERT MATERIAL? 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) ' LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.Dl m FTTI I I C I 1 1 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE 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 PLOILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE GROUND STORAGE TANK REGULATIONS FORM B (6-95) i FOR0034B-R7