COMPLIANCE INFO_1999-2005 - Laserfiche WebLink

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•i� g0 STATE OF CAUFORMA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM 'A COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. :v °`' 3a, MARK ONLY Q 1 NEW PERM? ®.3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION a 7 PERmANEN*k-4csEffl.lbwaITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVEDq+l DBA OR FACILITY NAME WHERE TANK IS INSTALLED: A. T e i c he r t & Son, Inc. I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK 1.D.• C-1 S. MANUFACTURED BY: Xerxes C. DATE INSTALLED(MOIOAYNEAR) September 1999 D. TANK CAPACITY IN GALLONS: 35, 000 II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. ® 1 MOTOR VEHICLE FUEL ❑ 4 OIL S. C. to REGULAR UNLEADED ® 3 DIESEL ❑ 8 AVIATION GAS A ,q ® t PRODUCT tb PREMIUM UNLEADED Q 4 GASAHOL 7 METHANOL ❑ 2 PETROLEUM F-1 80 EMPTYtc MIOGRADE MEAOED 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 OTHER(DESCRIBE IN REM 0.BELCH SS 0. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.r:: iAAf ILL TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C,AND ALL THAT APPLIES N BOX D AND E A. TYPE OF FX-j 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 ❑ t BARE STEEL ❑ 2 STAINLESS STEEL ® 3 FIBERGLASS ❑ 4 STEEL CLAD Wl FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 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 LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ® 8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES 1. 140— D.EXTERIOR 1 POLYETHYLENE WRAP 2 COATING 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION C:] 5 CATHODIC PROTECTION ® 91 NONE ❑95 UNKNOWN ® 99 OTHER E SPILL AND OVERFILL,�I., SPILLCONTIUNMEN7,INSTALLED(YEAR) OVERFILkPREVENTION EQUIPMENT INSTALLED(YEAR) _ I-I-+ DROP TUBE YES nA 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 A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U i 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 8 CONCRETE A U 7 STEELWI COATING A U 8 100%METHANOL COMPATIBLE WA=RP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER i tffCHAtAGLL tJtff tEAK 2 teff SNiilrt1E55 3 BIfERSTInA6 4 EIECTRCt1�LIIff 5 AUTOMATIC PIMP 99 OTHER D. LEAK DETECTION ❑ omcroR ❑ t ® wwoRm ❑ tfAK OETECT010 ® SHUTDOWN ❑ V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCILIATION ❑ 3 VAIDOZE MONITORING ❑ 4 GAUGING AUTOMATIC TANK ❑5 MON TORINGUND TER ❑8 TEsn TANK ® 7 MONITORING INTERSTITIAL ❑ 8 SIR ❑ 9 WEEKLY TANK A MANUAL®10 MONTHLY TANK ❑ 95 UNKNOWN ® 99 OTHER GING TESTI VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) t.ESTIMATED DATE LAST USED(MOIDAYNR) 2.ESTIMATED OUANTITY OF 1 3.WAS TANK FILLED WITH YES r7NO F7SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS SEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAMEDATE (Pl ITED a sKBNUTURE) George Takemori - 'z C9 Z 1 8-11-99 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPO D OF THE FOUR NUMBERS BELOW COUNTY K JURISDICTION M FACIUrf k TANK 0 STATE I.Dl m E [- FT71 I III PERMIT NUMBER LLPERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APKJQWN-FORM A.UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOTP LE THIS FORM WITH THE LOCAL AGENCY W THE GROUND STORAGE TANK REGULATIONS FORMS (8.95)