COMPLIANCE INFO_1987-1998 - Laserfiche WebLink

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gOURC ts STATE OF CALIFORNIA Pt wP + Or STATE WATER RESOURCES CONTROL BOARD i UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B W m `�•: o . COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. OSI If OR H,r MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 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.# ° 1111 ( - — B. MANUFACTURED BY: e r V a C. DATE INSTALLED(MO/DAYNEAR) I 1 D. TANK CAPACITY IN GALLO✓N`Sc. !`c II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. (✓ A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C ❑ is REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY EPS 1 PRODUCT ® 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ lc MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 3 CHEMICAL PRODUCT El95 UNKNOWN E] 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 Lel 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 [X 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 UNING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP �?4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION E::] 91 NONE ❑95 UNKNOWN 99 OTHER E.SPILL AND OVERFILL,etc. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES 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 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A 8>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 FfAl MECHANICAL LINE LEAK [:]2 LINE TIGHTNESS 3 CONTINUOUS INTERSTITIAL 4 ELECTRONIC LINE ,�yf,�5 AUTOMATIC PUMP DETECTOR TESTING MONITORING ❑ LEAK DETECTOR 'r-W SHUTDOWN ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL RECONCILIATION ORY F-] 3 VADOZE MONITORING 4 AUTOMATGAUGING IC TANK ❑ 5 GROUND MONITORING TER F-] 6 ANNUALTESTING EN 7 MONITOR CONTINUOUS E:] 8 SIR E:] 9 WEEKLY MANUAL ❑10 MONTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY 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 P INTED b SIGNA RIE) ' AW4, AML fir v LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPO D 4FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE 04 626 Z, PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIR TIQN D T I 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 ORM SHOULD BE ACCOMPANIED BY A PLOT PILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE GROUND STORAGE TANK REGULATIONS FORM B (6-95)