COMPLIANCE INFO_1985-1999 - Laserfiche WebLink

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sOVRCls STATE OF CALIFORNIA Me it `" STATE WATER RESOURCES CONTROL BOARD 3 UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM Bo 1 j •CSI IROR H,r, COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT >i_6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: aL)(K STelp /►1{At2 Ick( I Z S I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK 1.D.# I2S I B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) r I gs D. TANK CAPACITY IN GALLONS: , I p p�O II.TANK CONTENTS IF A-1 IS MARKED.COMPLETE ITEM C. A. 'EZ 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 ❑ 1c 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 ❑ 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 (P(mary Tank) ❑ 9 BRONZE 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING a 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING W6UNLINED ❑ 9✓5 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES4 NO_ D.EXTERIOR ❑ 1 POLYETHYLENE WRAP F__] 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE I io El95 UNKNOWN ❑ 99 OTHER SPILL CONTAINME 7 INSTALLED(YEAR) VER EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,etC. DROP TUBE YES NO STRIKER PLATE YES FIL P EVNO DISPENSER CONTAINMENT YES NO X IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION ACU)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 AW 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 19GALVANIZED STEEL A U 10 CATHODI PROTECTION A U 95 UNKNOWN 14 U 99 OTHER D. LEAK DETECTION M. 1 MECHANICAL LINE LEAK [:]2 UNE TIGHTNESS 3 CONTINUOUS INTERSTMAL 4 ELECTRONIC UNE 5 AUTOMATIC PUMP DETECTOR TESTING MONITORING ❑ LEAK DETECTOR SHUTDOWN ❑ 99 OTHER V.TANK LEAK DETECTION /11 ❑ VISUAL CHECK ❑ 2 RECONCILIATION MANUAL ORY ❑ 3 MONITORING VADOZE05 4 GAUGING AUTOMATIC TANK ❑ 5 GROUND MONITORINGTER ❑ 6 TESTINGNUAL TANK MONITOR NG INTERSTITIAL E:] 8 SIR El 9 WEEKLY MANUAL NT❑10 MONTHLY TANK ❑ 95 UNKNOWN ❑99 OTHER TANNG VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAYNR) �/� 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 THIS FORM HAS BEEN COMPLETED UNDER Pq A TY PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTED d SIGNATURE) I ✓��n 4- LOCAL AGENCY USE ONLY THE STA M RIS OMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# I STATE LDS m i f -rG ® I tl llk PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE 2L 6/ s THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICA FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM MUST BE COMPLETED INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLAW THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UROUND STORAGE TANK REGULATIONS FORM B (6-95)