COMPLIANCE INFO_1986-2002 - Laserfiche WebLink

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p'w- ..t. e' *,Ir :fit. _.y ... S i • tSpUAC�'y STATE OF CALIFORNIA p" •° °o: STATE WATER RESOURCES CONTROL BOARD 3 UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B • Com. .__ ..,► I. TANK DESCRIPTION COMPLETE ALL ITEMS - SPECIFY IF UNKNOWN A OWNER'S TANK I. D. # 1 4 .. 3 COMPLETE A SEPARATE FORM Fy EACH TANK SYSTEM. D. TANK CAPACITY IN GALLONS: E3 00 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION❑ 7 PERMANENTLY SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ jlll� 4 AMENDED PERMIT6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOV DBA OR FACILITY NAME WHERE TANK IS INSTALLED: G�o I kes-v=P A44 LiFT f' gid. (Primary Tank) I. TANK DESCRIPTION COMPLETE ALL ITEMS - SPECIFY IF UNKNOWN A OWNER'S TANK I. D. # 1 4 .. 3 B. MANUFACTURED BY: 5 ,o C. DATE INSTALLED (MO/DAY/YEAR) j C� D. TANK CAPACITY IN GALLONS: E3 00 II. TANK CONTENTS IF A-1 IS MARKED, COMPLETE ITEM C. A. ;Kj 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C ❑ to REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY " 1 PRODUCT 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ is MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOM 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 IET 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 55 9' UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES> NO— D. EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONEraAA 95 UNKNOWN ❑ 99 OTHER IuLZ2 SPILL CONTAINMENT INSTALLED (YEAR) OVERFILVPREVENTION EQUIPMENT INSTALLED (YEAR) / E. SPILL AND OVERFILL, EIC. DROP TUBE YES `/ NO STRIKER PLATE YES " NO DISPENSER CONTAINMENT YES NO LI' 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 A 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND 0 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 D. LEAK DETECTION1 MECHANICAL LINE LEAK ❑ 2 LINE TIGHTNESS O 3 CONTINUOUS INTERSTITIAL ❑ 4 ELECTRONIC LINE O 5 AUTOMATIC PUMP ❑ 99 DETECTOR TESTING MONITORING LEAK DETECTOR SHUTDOWN OTHER TA\ l V. I AIVI% LCAT% UC 1 Ctr I IUIV ❑ 1 VISUAL CHECK 2 MANUAL INVENTORY ❑ 3 VADOZEF 4 AUTOMATIC TANK ❑ 5 GROUND WATER 6 ANNUALTANK RECONCILIATION MONITORING GAUGING MONITORING TESTING ❑ 7 MON TOROUC'S INTERSTITIAL ❑ B SIR ❑ 9 WEEK LY MANUAL ❑ 10 MO TINLY 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 GALLONS N SUBSTANCE REMAINING -"" INERT MATERIAL? i THIS FORM HAS BEEN COMPLETED UNDER PE TY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTED& SIGNATURE) MIICIF ter( 10 cle� el LOCAL AGENCY USE ONLY THE STATE I.D_.NUMBER IS CO OSED OF THE FOUR NUMBERS BELOW I COUNTY # JURISDICTION # FACILITY # TANK # STATE I.D.# II 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. F C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT ILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THRGROUND STORAGE TANK REGULATIONS FORM B (6.95)