COMPLIANCE INFO_1986-2002 - Laserfiche WebLink

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' .. T. � ., 1. :, ". . �. .. ,�: .. t' �, .. it i ,:.. ...' S' � ': 7 :: ke .. 79.. 7' • SOV NCtg t STATE OF CAUFORNIA STATE WATER RESOURCES CONTROL BOARD ; UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B • C�l+FO++N' COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ `1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 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: QV I K STOP i►'IAAK(r ❑ 2 STAINLESS STEEL I. TANK DESCRIPTION COMPLETE ALL ITEMS - SPECIFY IF UNKNOWN A OWNER'S TANK I. D. # j -i a B. MANUFACTURED BY: lC r -.n Y,& 4 x � C, ❑ to REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS - C. DATE INSTALLED (MO/DAYNEAR)= j _ - D. TANK CAPACITY IN GALLONS: 10/000 II. TANK CONTENTS IF A-1 IS MARKED, COMPLETE ITEM C. q T .'..I. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C, ❑ to REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY Q-1 1 PRODUCT ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL �1C MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELONG 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 . E = 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 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YESZ NO— INTERSTITIAL ❑ 4 ELECTRONIC ONE 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 OVERFILL.PREVENTN EQUIPMENT INSTALLED (YEAR) ,t E. SPILL AND OVERFILL EtC. SPILL CONTAINMENT�NSTALLED (YEAR) IO + DROP TUBE YES v NO STRIKER PLATE YES IV 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 {U 412 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A_ U1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND Ax's) 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC)A U 4 FIBERGLASS PIPE J ~U 3. WAS TANK FILLED WITH CORROSION A 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 1 MECHANICAL LINE LEAK Q 2 ONE TIGHTNESS ❑ 3 CONTINUOUS INTERSTITIAL ❑ 4 ELECTRONIC ONE ❑ 5 AUTOMATIC PUMP ❑ 99 OTHER TESTING MONITORING LEAK DETECTOR SHUTDOWN V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ ❑ 7 CONMON INUOUC'S INTERSTITIAL ❑ ORINVI. 2 MANUAL RECONCILIATION ORY ❑ 3 VADOZE MONITORING `�..4 AUTOMATGAUGING IC TANK 8 SIR ❑ 9 WEETANKLYMANUAL ❑ 10 MOTESTINGHLY TANK ❑ 5 GROUND MONITORING ❑ 95 UNKNOWN ❑s 6 TANK TESTING ❑ 99 OTHER TANK CLOSURE INFORMATION (PERMANENT CLOSURE IN-PLACE) 1. ESTIMATED DATE LAST USED (MO/DAY/YR) J 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PEN OF PER TANK OWNER'S NAME (PRINTED &SIGNATURE) / f^� LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSEb COUNTY # JURISDICTION # STATE I.D.1 PERMIT NUMBER PERMIT APPROVED BY/DATE AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT OF THE FOUR NUMBERS BELOW FACILITY # TANK # PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT AP ON -FORMA, UNLESS A CURRENT FORMA HAS BEEN FILED. F M C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLO THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THRGROUND STORAGE TANK REGULATIONS FORM B (6-95) m �o