COMPLIANCE INFO_1999-2007 - Laserfiche WebLink

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acea STATE OF CALIFORNIA • �..,., c� STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. c"`"'"",►' MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE E:] 8 TANK RE DBA OR FACILITY NAME WHERE TANK IS INSTALLED: CH L I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN iv- A. OWNER'S TANK 1.D.# 2 B. MANUFACTURED BY: X 5r< x e C Ica C. DATE INSTALLED(MO/DAYNEAR) '� 15 D. TANK CAPACITY IN GALLONS: 15 G J(�"� II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A• JZ 1 MOTOR VEHICLE FUEL ❑ 4 OIL g. C. ❑ to REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN2 WASTE 1C MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ ❑ 2 LEADED ❑ D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED 99 OTHER(DESCRIBE IN ITEM D.BELONn 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 ;�Q 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 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 i LINING OR ❑ 5 GLASS LINING ® 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 10D% METHANOL? YES_ NO— D.EX O_D•EX BOSTON ❑ 1 POLYETHYLENE WRAP F-12 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,BtC. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES `'+ NO STRIKER PLATE YES A^� 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 E2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL AU 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 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 MECHANICAL UNE LEAK ❑2 UNE TIGHTNESS g 3 C—NL00S WTERSM& ❑4 ELECmOMC UNE 5 AUTOMATIC PUMP DETECTOR TESTING J� MONTORMG CEAI(DETECTOR SHUTDOWN ❑99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL INVENTORY ❑ E] 4 AUTOMATIC TANK 5 GROUNDWATER ❑3 VADOZE 6 ANNUAL TANK 7 RECONCILIATION MONITORING GAUGING ❑ MONITORING TESTING MONITORING NUOUS INTERSTITIAL ❑ 8 SIR ❑ 9 WEEKLY MANUAL ❑10 MONTHLY TANK ❑ 95 UNKNOWN ❑99 OTHER TANK GAUGING TESTING- VI-TANK ESTINGVI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) HA LESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES ❑ NO❑ T�HIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT rcyclvr jP K OWNER�6NAME LTED 8 SIGNATURE) I I L ► f i4 C RRir 1 N�- �,Q DATE 11-11-9 I S SU 1'ITwl-- I cl i 7 N, M P'WI!A- BLup VJfu) , of - 1$-, " Z1°suomrrTAL t LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D:# �❑ ❑❑❑ a 8 l�s? 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 PLAN.-_ R]LE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNpgpGROUNO STORAGE TANK REGULATIONS FORM B (6.95) PLAT i6 s