COMPLIANCE INFO_1998-2006 - Laserfiche WebLink

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0 0 A. .Ok' Ab STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD 0 UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B o 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 F--] 6 TEMPORARY TANK CLOSURE E] 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: (eyo (qeal I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) /0// D. TANK CAPACITY IN GALLONS: 15 e2O 11.TANK--CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. to REGULAR UNLEADED E—] 3 DIESEL F--j 6 AVIATION GAS A. JVT I MOTOR VEHICLE FUEL ❑ 4 OIL B. C. y'lllb PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ 80 EMPTY N-11 I PRODUCT 1c MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT E:] 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.#: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER E:] 5 INTERNAL BLADDER SYSTEM [:] 95 UNKNOWN C9 SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT El 99 OTHER B. TANK ❑ 1 BARE STEEL F7 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLEW/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. NO— D.EXTERIOR F--] 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION 5 CATHODIC PROTECTION [::] 91 NONE ❑95 UNKNOWN ❑ 99 OTHER PROTECTION ❑ SPILL CONTAINMENT INSTALLED(YEAR) I f&/ OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,etC- DROP TUBE YES NO_ STRIKER PLATE YES 4 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 AOU 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A fp2 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)Ag 4 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 0DETECTOR 1 MECHANICAL LINE LEAK [:]2 LINE TIGHTNESS M3 CONTINUOUS INTERSTITIAL 4 ELECTRONIC LINE 5 AUTOMATIC PUMP 0 99 OTHER D. LEAK DETECTION "-J TESTING MONITORING LEAK DETECTOR 2� SHUTDOWN V.TANK LEAK DETECTION 2 MANUAL INVENTORY F] 3 VADOZE rVT 4 AUTOMATIC TANK [:] 5 GROUND WATER ❑ 6 ANNUALTANKI El 1 VISUAL CHECK RECONCILIATION MONITORING Ll�,�J GAUGING MONITORING TESTING E;Z 7 CONTINUOUS INTERSTITIAL E::] 9 WEEKLY MANUAL E]10 MONTHLY TANK E] 95 UNKNOWN ❑ 99 OTHER MONITORING ED 8 SIR ❑ TANK GAUGING TESTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ES IMA)q/j E LAST USED(MO/DAYNR) T—2.ESTIIMATED QUANTITY OF 3.WAS TANK FILLED WITH T SUBSTANCE REMAINING _GALLONS INERT MATERIAL? YES [7 NOE] THIM HAS BEEN UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRqEAVD CORRECT DATE If'4�(PRINT OWNER'SjVA-E 1115- R RE E) (PRINTED&SIGNY ) , LOCAL AGENCY USE ON6v THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# C) STATE I.D.4 = o q 0 FgTM-olla4 mono PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APP ON-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 JW FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING TWRGROUND STORAGE TANK REGULATIONS FORM B (6-95)