COMPLIANCE INFO_1999-2005 - Laserfiche WebLink

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R „es �^eta STATE OF CAUFORNIA a °t STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B e COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ® 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMAN SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: A. Te i c he r t & Son, Inc. I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN 53 A. OWNERS TANK 1.0.♦ WO-7 S. MANUFACTURED BY: Xerxes ® � C. DATE INSTALLED(MOIDAYNEAR) September 1999 0. TANK CAPACITY IN GALLONS: 2, 500 II.TANK CONTENTS IF A•1 IS MARKED,COMPLETE ITEM C. A. ❑ 1 MOTOR VEHICLE FUEL ® 4 OIL EL to REGULAR UNLEADED H 3 DIESEL ❑ 6 AVIATION GAS 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT tb PREMIUM UNLEADED 4 GASAHOL (� 7 METHANOL lc MIDGRADE UNLEADED 5 JET FUEL lrR 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ® 2 WASTE ❑ 2 LEADED 0 99 OTHER(DESCRIBE IN ITEM D.BELOW) 0. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.0: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOX 0 AND E A. TYPE OF © I 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 WIFRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ® 3 EPDXY UNING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ® 6 UNLINED ® 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL 7 YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION Cl 91 NONE ®95 UNKNOWN ❑ 99 OTHER SPILL CONTAINMENT RSTALLED(YEAR) OVERFi PREVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,etc. DROP TUBE YES n NO STRIKER PLATE YES A ND 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@ 2 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 C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A 0 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL WI COATING A U 8 toa%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 [D' L"4 LEAK ®z uMI 4:01 Ess ®3 caatxArous mrERSTnuI 4 EiECTRQAC Ld1E ❑s AtrrolunC rina 99 OTHER DETECTOR TESTING MOMT01114 LEM OE ECTOR SHUTDOWN V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCIINVENTORY ONORY ® 3 VMO MONITORING ❑ 4 GAUGING AUTOMATIC TANK ®5 MON MONITORING WATEROUND ❑6 TESTING ® 7 MON TOR U INTERSTITIAL ❑ 8 SIR ❑ 9 WEEKLYA MANUALrZI ®10 MONTHLY TANK ❑ 95 UNKNOWN ®99 OTHER TESTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAYA M 2.ESTIMATED OUANTTY OF 3.WAS TANK FILLED WITH ,ES ❑ NO❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 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 (PRINTE06s*NAnME) George TakemoriAla,, 8-11-99 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMP I ED OF THE FOUR NUMBERS BELOW COUNTY x JURISDICTION 0 FACILITY k TANK a STATE I.D.1 PERMIT NUMBER PERMIT APPROVED SY/OATE PERMIT EXPIRATION DATE THIS FORAM MUST BE ACCOMPANIED BY A PERMIT AP .FORM A.UNLESS A CURRENT FORM A HAS BEEN FILED. FO UST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT pLWLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UJWROUNO STORAGE TANK REGULATIONS FORMS (6.95)