COMPLIANCE INFO_1987-1998 - Laserfiche WebLink

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0 "ouaces STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD ; g UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B F • Cit IIOR NI COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY RZ1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS ON SITE ONE ITEM ET 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# 1 i I 4 7 -0 B. MANUFACTURED BY: f-5. 0q- C. DATE INSTALLED(MO/DAYNEAR) 16"? D. TANK CAPACITY IN GALLONS: /1 II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. v� A. [y♦ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C ❑ to REGULAR UNLEADED 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM 80 EMPTY � 1 PRODUCT 1b PREMIUM UNLEADED ❑ 4 GASAHOL E:] 7 METHANOL ❑ ❑ ❑ 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 x 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 0 2 STAINLESS STEEL UX 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLEW/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 LINING OR 0 5 GLASS LINING �o 6 UNLINED 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR ❑ i POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑164 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,etc. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL FBEVENTION EQUIPMENT INSTALLED(YEAR) 1 1-1 DROP TUBE YES J NO STRIKER PLATE YES_(Z_ 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 02 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 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A,7lp4 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 LINE LEAK 2 LINE TIGHTNESS 3 CONTINUOUS INTERSTITIAL 4 ELECTRONIC UNE o 5 AUTOMATIC PUMP 4�1 DETECTOR TESTING MONITORING LEAK DETECTOR SHUTDOWN ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL RECONCILIATION MONITORING F-] VADOZE TANK 3 MONIITORING 4 AUTOMATGAUGING IC TANK ❑ 5 GROUND MONITORING TER ❑ 6 ANNUALTESTING 7 MONITORU INTERSTITIAL ❑ 8 SIR ❑ 9 WEETANKLY MANUAL ❑10 MO TINLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) FIMATEDESTDATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES ❑ NO:Ef] THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAMEA DATE (P TED&SIG TUBE) .-F (_�. g 1 !(IJC.I. G� LOCAL ArBrf USE ONLY THE STATE I.D.NUMBER IS COM SE TH OUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D:#Z3�o m771 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION TE ( THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLI N-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. F MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THEGROUND STORAGE TANK REGULATIONS FORM B (6-95)