COMPLIANCE INFO_2009-2018 - Laserfiche WebLink

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h, tgOURC�s STATE OF CALIFORNIA Lp" STATE WATER RESOURCES CONTROL BOARD 3 1 UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B • Off!/FOR N'I' COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CCLLIOSURE�/ ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. I ANK UhbL;HIFI IUN COMPLETE ALL ITEMS - SPECIFY IF UNKNOWN A OWNER'S TANK I. D. # B. MANUFACTURED BY: C. DATE INSTALLED (MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: II TAAIV ^^kITC\ITN I. AAAA\ VVI\14.11IV Ir M- I IJ MMMNMU, UUMr= I C I 1 CM l.. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C to REGULAR UNLEADED ❑ 3 DIESEL [—]6 AVIATION GAS ^ ❑ 2 PETROLEUM ❑ 80 EMPTY ( JJV 1 PRODUCT ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL 714 SINGLE WALL IN A VAULT 99 OTHER ❑ 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. # : 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A, B, AND C, AND ALL THAT APPLIES IN BOX D A96 E A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER5 A INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM El2 SINGLE WALL 714 SINGLE WALL IN A VAULT 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ASS ❑/7UMINUM ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ ❑8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑10 GALVANIZED STEEL ❑WN ❑ 99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING E]6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANO YES— NO— A U 95 UNKNOWN D. EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING F-]3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E. SPILL AND OVERFILL, etc. SPILL CONTAINME T NSTALLED (Y ) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) LEAK DETECTOR DROP TUBE YES 2S, NO STRIKER PLATE YES° NO DISPENSER CONTAINMENT Y S NO IV. PIPING INFORMATION CIRCLE'A IF ABOVE dROUND OR U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION 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 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 GALVA ED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A 99 OTHER D. LEAK DETECTION yl MECHANI LINE LEAK O 2 LINE TIGHTNESS ❑ 3 CONTINUOUS INTERSTITIAL [:j4 ELECTRONIC LINE 5 AUTOMATIC PUMP ❑ 99 OTHER DETECT TESTING MONITORING LEAK DETECTOR SHUTDOWN V. TANK LEAK DETECTIO El 1 VISUAL CHECK ❑ 2 RECONCILIATIONMANUAL INVENTORY ❑ 3 MONITORING ANNUAL[-]VADOZE4 GAUGING AUTOMATIC TANK E]5 MONITORING GROUND TER ❑ 6 TESTINGTANK ❑ 7 CON TORINWORN INTE STITTANK GAUGING IAL ❑ 8 SIR E::]9 WEEKLY MANUAL ❑ 10 MONTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI. TANK CLOSUR 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 (PRINTED& SIGNATURE) 1 LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # I qC4 TANK #' STATE LD:# 'ERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE [HIS 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 PLA&FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE�RGROUND STORAGE TANK REGULATIONS 1 FORM B (6-95) — I c)✓ 7? _$