COMPLIANCE INFO_1986-1997 - Laserfiche WebLink

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a �o -CC. STATE OF CALIFORNIA Dego STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B F COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY F_j 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM F-1 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: r,heuj-c)- 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.It B. MANUFACTURED BY: S C. DATE INSTALLED(MO/DAY/YEAR) 1526 D. TANK CAPACITY IN GALLONS: CJ 11.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. R] 1 MOTOR VEHICLE FUEL F__] 4 OIL B. C. ❑ la REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY I PRODUCT ❑ lb PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL N Ic MIDGRADE UNLEADED ❑ 5 JETFUEL ❑ 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.#: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF X) 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER E 5 INTERNAL BLADDER SYSTEM [—] 95 UNKNOWN SYSTEM Ej 2 SINGLE WALL El 4 SINGLE WALL IN A VAULT E:] 99 OTHER B. TANK F__] I BARE STEEL ❑ 2 STAINLESS STEEL [g] 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL F__j 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM E] 8 100% METHANOL COMPATIBLEW/FRP (Primary Tank) E] 9 BRONZE ❑ 10 GALVANIZED STEEL [:] 95 UNKNOWN 99 OTHER C.INTERIOR F-1 I RUBBER LINED ❑ 2 ALKYD LINING F-] 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR F__] 5 GLASS LININGK71 6 UNLINED F__j 95 UNKNOWN F-] 99 OTHER vw COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES® NO— D.EXTERIOR E-1 1 POLYETHYLENE WRAP F__j 2 COATING F-1 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION Ej 5 CATHODIC PROTECTION [:] 91 NONE PQ 01, 0 95 UNKNOWN ❑ 99 OTHER SPILL CONTAINME T NSTALLED(YEAR)—Z z:0 OVERFILJPREVENTION EQUIPMENT INSTALLED(YEAR) /!Z2!2lf_r E.SPILL AND OVERFILL,etC- DROP TUBE YES NO STRIKER LATE YES NO DISPENSER CONTAINMENT YES— NO_-6.— IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U I SUCTION A?U; PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A6)i 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(D4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLEW/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER NESS 0 3 CONTINUOUS INTERSTITIAL 4 ELECTRONIC LINE 5 AUTOMATIC PUMP D. LEAK DETECTION W,mEcHAN'cAL LINE' E 99 OTHER DETECTOR MONITORING ❑ LEAK DETECTOR ❑ SHUTDOWN V.TANK LEAK DETECTION ❑ I VISUAL CHECK FFl MANUAL INVENTORY 3 VADOZE ❑ 4 AUTOMATIC TANK ❑5 GROUND WATER ❑ 6 ANNUAL TANK MGAUGING TESTING 7 CONTINUOUS INTERSTITIAL 8 SIR RECONCILIATION El 9 WEEKLYONITORING MANUAL ❑10 MONTHLY TANK ❑ 95MONITORING UNKNOWN ❑99 OTHER MONITORING TANK GAUGING TESTING 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 I SUBSTANCE REMAINING YES INERTMATERIAL? 1-1 0 NO❑ 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 TURE) (PRINTED&SIGNA LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE OUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.4 m F-FT-1 I I I I I 1 -1 1 1 1 r1 1 1 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. FORM C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLAN. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (6-95)