COMPLIANCE INFO_1998-2006 - Laserfiche WebLink

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0 .s°UNCfs STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD 3 ° UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B .0 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ® 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE N ITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED C) I DBA OR FACILITY NAME WHERE TANK IS INSTALLED:C 4V 6 L TANK DESCRIPTION COMPLETE ALL ITEMS – SPECIFY IF UNKNOWN A. OWNER'S TANK I. D. #MA 0/ B. MANUFACTURED BY: I )Cr , f� C. DATE INSTALLED(MO/DAYNEAR) i $ D. TANK CAPACITY IN GALLONS:(. Q®® II TANK CnNTFNTS IF A-1 IR MAbKEJ COMPLETE ITEM C. A� 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. 1 PRODUCT C la REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ lb PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL F7 2 PETROLEUM ❑ 80 EMPTY SYSTEM ❑ lc MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 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. #: 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 F__]95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. CONSTRUCTION ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC B. TANK 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? YES— NO— D. EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION ❑ CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER PROTECTION 5 aae lnnp E. SPILL AND OVERFILL, etc. SPILL CONTAINMEN DROP TUBE YE OVERL PREVENTION EQUIPMENT INSTALLED (YEAR) STALLED (YEAR) FI1 NO STRIKER PLATE YE NO DISPENSER CONTAINMENT YES NO IV PIPINr; INFORUATInN faacl F A IF AROVF GROUND OR U IF UNDERGROUND. BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND CORROSION PROTECTION A U A U A U 1 BARE STEEL 5 ALUMINUM 9 GALVANIZED STEEL A U A U A U 2 STAINLESS STEEL A U 6 CONCRETE A U 10 CATHODIC PROTECTION 3 POLYVINYL CHLORIDE (PVC) A DFIBERGLASS PIPE 7 STEEL W/ COATING A U 8 100% METHANOL COMPATIBLE W/FRP A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 MECHANICAL UNE LEAK DETECTOR ❑ 2 UNE TIGHTNESS CONTINUOUS INTERSTITIAL " 4 ELECTRONIC UNE - TESTING MONITORING LEAK DETECTOR 5 AUTOMATIC PUMP 99 OTHER SHUTDOWN ❑ V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK r 2 RMANUAL ECONCIUATIONORY ❑ 3 MONIITORING OZE 4 AUTOMATGAUGING MONITORING TANK ❑ 5 GROUND MONTORINGTER ❑ 6 TES"TINGTANN 7 CONTINUOUS tMONITORING INTERSTITIAL ❑ 8 SIR ❑ 9 WEEK LY MAN NUAL ❑ 10 MO NTHLY TING TANK El 95 UNKNOWN ❑ 99 OTHER VI. TANK CLOSURE INFORMATION (PERMANENT CLOSURE IN-PLACE) 1. ESTIMATED DATE LAST USED (MO/DAYNR) 2. ESTIMATED QUANTITY OF3. WAS TANK FILLED WITH YES ❑ NO ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL ? ,K PERAURY, AND O THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT THIS FORM HAS BEEN COMPLETED UNDER PENALTY 01 TANK OWNER'S NAME 8 SIGNATURE) J` DATE,// (PRINTED 1 LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # Ar TANK #�- i STATE I.D.4I _M F I I I I El� ' 1/ 1-71 Ll� 11014 PERMIT NUMBER I P RMIT APPROVED BY/DATE I PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLWMN - FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. FAW MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT POWLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THEJWGROUNO STORAGE TANK REGULATIONS FORM B (6-95)