COMPLIANCE INFO_1999-2003 - Laserfiche WebLink

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STATE OF CALIFORNIA -t�o�wcea. °O STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B COMPLETE A SEPARATE FORM FOR,EACH TANK SYSTM MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 1741 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON St ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 5 TEMPORARY TANK CLOSURE ® 8 TANK REM6E-O t!� /,5,447 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: i I v ;T 11 1 C—) :,447 1. TANK DESCRIPTION COMPLETE ALL ITEMS-SPECIFY IF UNKNOWN A. OWNERS TANK 1.0.k ;l-1 /' I S. MANUFACTURED 3Y: yQ�tp� C. DATE INSTALLED(MO/OAY/YEAR) T I D. TANK CAPACITY IN GALLONS: 0490 IL TANK CONTENTS IF A-1 IS MARK.COMPLETE ITEM C. A. Co 1 MOTOR VEHICLE FUEL ❑ A OILB G { 1 to REu4lL1H UNLEADED Q 3 DIESEL (❑ 8 AVIATION GAS F7 2 PETROLEUM ® 80 EMPTY 1 PRODUCT (� lb PRE 1M UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ tc MIDGRADE UNLEADED5 JET FUEL- ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED Ed 99 OTHER(DESCRIBE IN ITEM 0.BELOW) 0. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.k III. TANK CONS ,TR iUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOX 0 AND E A. TYPE OF 09 1 DOUBLE WALL ❑ 3 SiNGLe WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM! ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALT. ❑ 4 SINGLE WALL IN A VAULT I ] 99 OTHER B. TANK ❑ t BARE STEEL ❑ 2 STAINLESS STEEL ( 3 FIBERGLASS i❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100%w METHANOL COMPATIBLE WIFRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 9S UNKNOWN I❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑I 3 EPDXY LINING 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 [7 2 COATING i 3 VINYL WRAP � 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 PROTECTION C:] 91 NONE — El95 UNKNOWN I� 49 OTHER E SPILL AND OVERFILL,etc SPILL CONTAINMENT INSTALLED(YEAH OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES NO STRIKER PLATE YES gj== NO DISPENSER CONTAINMENT YES NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IFAPPUCABLE 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 t 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 U 4 FIBERGLASS PIPE CORROSION A U 5 AURMUM A U 6 CONCRETE A U 7 STEEL WICOATIN i A U 8 100 METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHOOIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION [l�I1 LM LEAK ❑2 tart t1c.WN oma ❑4 aF1:Is C U E r1S�'t 5,une.. C:]99 on,aa OEM= 1ES7W0 womToRwo LFAK IEMMOR �W 9W700" V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK F72 MANUAL INVENTRECONCILIATION RY r73 VADOZE MONITORING 4 GAUGING TANK ❑5 TOR,UND GTER ❑o ANNUALTESTING 7 MONITORING WTERSTMAL ® 8 SHR ❑ 9 WEEKLY T GAUGING ®10��Y TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAY/YR) I 2.ESTIMATED QUANTITY OF I 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 NAMEp� ® DATE ys /fig i►� (PRINTED^GruT rA l �✓/ LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER 1S COMPO CN/FOUR NUMBERS BELOW JL j COUNTY# JURISDICTION# FACIUTY* TANK#6tt 7I r STATE I.D: PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION OA Tf� THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLID"^ON-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED.FORM C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOWTAL LLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING TH . - 9GROUND STORAGE TANK REGULATIONS FORM 8 (6-95)