COMPLIANCE INFO_1986-2002 - Laserfiche WebLink

Home Browse Search

• Ptsounc,s� STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD ; UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B W �' • cel lfO�N'f COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT Vo5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS TE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: QU ( K STOP ftlAO2kE-7 */21 I. TANK DESCRIPTION COMPLETE ALL ITEMS - SPECIFY IF UNKNOWN A OWNER'S TANK 1. D. # I ,1 I y B. MANUFACTURED BY: C. DATE INSTALLED (MO/DAYNEAR) 'q 89 D. TANK CAPACITY IN GALLONS: ��o d Q II. TANK CONTENTS IF A-1 IS MARKED, COMPLETE ITEM C. A. ,�1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C ❑ to REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY IR -1 PRODUCT ❑ lb PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL 1c MIDGRADE UNLEADED ❑ 5 JET FUEL E::]8 M85 ❑ 3 CHEMICAL PRODUCT El 95 UNKNOWN El 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 ❑ 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 �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 LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 6 UNLINED �95 NKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— DETECTOR D. EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 5 UNKNOWN ❑ 99 OTHER 1 E. SPILL AND OVERFILL CtC. SPILL CONTAINMENT 1 DROP TUBE YES TALLED (YEAR) OVERFIL REVENTION EQUIPMENT INSTALLED (YEAR) Ll -17 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 AG) 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& 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 GALVANIZED STEEL U 10 CATHODIC PROTECTIONA U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 MECHANICAL LINE LEAK 2 U[:]NE TIGHTNESS 3 CONTINUOUS INTERSTITIAL 4 ELECTRONIC UNE 5 AUTOMATIC PUMP ❑ [:]SHUTDOWN ❑ 99 OTHER DETECTOR TESTING MONITORING LEAK DETECTOR 1. TANK LEAK DETECTION D 1 VISUAL CHECK D 2 RECONCILMANUAL II TIIONVENTORY F-13 MONITORING VADOZE ®4 GAUGING AUTOMATIC TANK E]5 MON TORINGGROUND WATER ❑ 6 ANNUAL TESTINGTANK ❑ 7 CONTINUOUS MONITORING INTERSTITIAL El 8 SIR ❑ 9 WEEKLY GAUGING AL E]10 MONTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI. TANK CLOSURE INFORMATION (PERMANENT CLOSURE IN-PLACE) 1. ESTIMATED DATE LAST USED (MO/DAY/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH /J.141 SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENAIT4 OF PER Y, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAMDATE E I (PRINTED 6 SIGNATURE) KF / of oe � LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOS D OF THE FOUR NUMBERS BELOW �j COUNTY # JURISDICTION # FACILITY # TANK # STATE I.D.4 Y�mhi� PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE L q � '�JD� THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLIC TION - 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 P4PFILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THvRGROUND STORAGE TANK REGULATIONS FORM B (6-95)