COMPLIANCE INFO_1999-2005 - Laserfiche WebLink

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0 0 { '° ,,s ^Cgs STATE OF CALIFORNIA •w•'• t STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. t -11 MARK ONLY ® i NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMAN Y O SITE ONE ITEM f72 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE © 8 TANK REMOVED .. DBA OR FACILITY NAME WHERE TANK(SINSTALLED. A. Teichert & Son, Inc. ' I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.0.11 C-2 B. MANUFACTURED BY: Xerxes C. DATE INSTALLED(MO/DAY/YEAR) September 19 9 9 0. TANK CAPACITY IN GALLONS: 15, 000 10.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. 1 In REGULAR UNLEADED 3 DIESEL 8 AVIATION 1 MOTOR VEHICLE FUEL 4 OIL B. A ® F-1c GAS �js 9b PREM8IM UI�EAOt� � 4 GASAHOL 7 METHANOL /yJ/J1/y ❑ 2 PETROLEUM F-11 PRODUCT so EMPTY is MDGRADE UNLEADED 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT CD 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 OTHER(DESCRIBE IN ITEM 0.BELOW) 0. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.t NI. 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 ❑ 8 100%METHANOL COMPATIBLE W/FRP (PrIMMY Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ® 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ® 8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES-X- NO_ D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 ViNYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHOOIC PROTECTION ® 91 NONE ❑95 UNKNOWN ® 99 OTHER E SPILL AND OVERFILL,etc. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED-(YEAR) DROP TUBE YES_.X._ NO STRIKER PLATE YES.X_ 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 U2&RESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U V 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® 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 8 CONCRETE A U 7 STEEL W/COATING A U s t00% 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 °* u*" ❑ TE5Taa1 2 TrcrlMtW ®3 ❑4�WROMC Ula: �5 AUTOMATIC PUMP C] 99 OTHEROTHERaETEC= IRWIORM LEAK OMCTOA 94ADOWIN V.TANK LEAK DETECTION ® 1 VISUAL CHECKF-12 RENCONCILIATION RY F73 MONITZORING ❑VADOE 4 GAUGING AUTOMATIC TANK f75 GROUMONITND WATER ORiNG r-78 ANNUALTESTING ® 7 ASN TORONUGS INTERSTITIAL ❑ 8 SIR ® 9 EEKLNK A MANUAL❑10 MONTHLY TANK F-195 UNKNOWN ❑99 OTHER UGING TESTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE iN-PLACE) i.ESTIMATED DATE LAST USED(MO/DAYIYR) 2.ESTIMATED OUANiiTY OF 3.WAS TANK FILLED WITH YES ❑ NO❑ SUBSTANCE REMAINING GALLONS 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 a SKINATME) George Takemori 18-11-99 LOCAL AGENCY USE ONLY THE STATE LD.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY A JURISDICTION N FACILITY M TANK K STATE LD:# C❑ PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION!DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT AP -FORM A.UNLESS A CURRENT FORM A HAS BEEN FILED. FOW MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PjjgfU THIS FORM WITH THE LOCAL AGENCY IMPLEI4w GROUND STORAGE TANK REGULATIONS FORMS (8.95)