COMPLIANCE INFO_1997-2001 - Laserfiche WebLink

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Y ' EsoV Cps. STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. 7 PERMANENTLY ON SITE MARK ONLY ❑ ,1.NEW..PERMIT a 3 RENEWAL PERMIT �. S CHANGE-OF.INFORMATION � � ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSUREr,8 TANK REMOVE DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK 1.D.It 0 awf,A A t, B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A. [Z,1 MOTOR VEHICLE FUEL a 4 OIL B. C L__j 1a REGULAR UNLEADED a 3 DIESEL 6 AVIATION GAS 1b PREMIUM UNLEADED 4 GASAHOL 7 METHANOL El 2 PETROLEUM 80 EMPTY ,.,1 PRODUCT El 1c MIDGRADE UNLEADED E::] 5 JET FUEL 8 M85 3 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE El 2 LEADED 0 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 O 1 DOUBLE WALL F--] 3 SINGLE WALL WITH EXTERIOR LINER 5 INTERNAL BLADDER SYSTEM E:] 95 UNKNOWN SYSTEM may( 2 SINGLE WALL O 4 SINGLE WALL IN A VAULT ED 99 OTHER B. TANK I 1 BARE STEEL F-] 2 STAINLESS STEEL F] 3 FIBERGLASS O 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL F-1 r5 CONCRETE F-� 6 POLYVINYL CHLORIDE F-1 7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) 9 BRONZE 10 GALVANIZED STEEL a 95 UNKNOWN 99 OTHER E" C.INTERIOR F-1 1 RUBBER LINED O 2 ALKYD LINING 3 EPDXY LINING a 4 PHENOLIC LINING LINING OR F-� 5 GLASS LINING I g'6 UNLINED F-1 95 UNKNOWN 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR 0 1 POLYETHYLENE WRAP F-� 2 COATING El 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION 5 CATHODIC PROTECTION E:l 91 NONE F�*5 UNKNOWN 0 99 OTHER SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENT�ON,EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,EtC. DROP TUBE YES «. NO- 1 PLATE YES NO DISPENSER CONTAINME YE 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&k SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A 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 1 MECHANICAL UNE LEAK 2 UNE TIGHTNESS 3 CONTINUOUS INTERSTITIAL 4 ELECTRONIC U _ NE 5 AUTOMATIC PUMP D. LEAK DETECTION DETECTOR a TESTING MONITORING LEAK DETECTOR SHUTDOWN ❑ 99 OTHER V.TANK LEAK DETECTION ] 1 VISUAL CHECK A!S ECONCIL2 MANUAL IATIONENTORY 3 MONITORING VADOZEa 4 AUTOMATGAUGING IC TANK 5 GROUND MONITORING TER 6 TETANK STING 7 MONITORING INTERSTITIAL D 8 SIR Q 9 WEEK LY MANUAL 10 MO TINLY TANK 0 95 UNKNOWN El 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DAT�LAST WMO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES a NO do -?r�I SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PEY, D TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME DATE .; (PRINTED 6 SIGNATURE) S +�3 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF TH OUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.4 m FM I I I I I 1 1 11111,7, 1 riI PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLAN. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (6-95)