COMPLIANCE INFO_1998-2006 - Laserfiche WebLink

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'te w�cF STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B m -x COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY VQ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED D I DBA OR FACILITY NAME WHERE TANK IS INSTALLED: y SSI I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN IIIg y A OWNEF'S TANK I.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: `r 5` O� Ii.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A / MOTOR VEHICLE FUEL ❑ 4 OIL g. C. ❑ 1a REGULAR UNLEADED F-13 DIESEL [:] 6 AVIATION GAS �y�' 1b PREMIUM UNLEADED O 4 GASAHOL ❑ 7 METHANOL F72 PETROLEUM ❑ 80 EMPTY iP[ I 1 PRODUCT E91,11C MIDGRADE UNLEADED ❑ 5 JET FUEL [::] 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN G "O� 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 0 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL T5r 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE F-1 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PHimaryTa"k) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED a 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 10D% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP O 2 COATING ❑ 3 VINYL WRAP )Kr4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE jnjV ❑95 UNKNOWN ❑ 99 OTHER ch eno(7 E.SPILL AND OVERFILL etc. SPILL CONTAINME I TALLED(YEAR) OVER ILL ER EVENTION EQUIPMENT INSTALLED(YEAR) + DROP TUBE YES NO STRIKER PLATE YES NO DISPENSER CONTAINMENT YE NO IV.PIPING INFORMATION CIRCLE A IF ABOVE,2,ROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A m PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL AQ)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) 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 CATH O IC PROTECTION A U 95 UNKNOWN U 99 OTHER D. LEAK DETECTION 1 MHEHXAMCAL LINE LEAK2 LINE TIGHTNESS 3 GONNG MAIOUS WMSTMAL 4 BACTRIM UNE 5 AUTOMATIC PUMP a DETECTOR [:] TESTIM ONffOF G em DETECTOR 94UTUM 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 ARECONCILIATION AEECONCIL ATIONORY ❑ 3 M�ORING 4 GAUGING IC TANK E]5 GROUND MONITORING TER 6 TENUAL TANK STING 7 CONTINUOUS N3 MONITORING INTERSTITIAL 8 SIR ❑ 9 TgNK GAUGING ❑10 M STING 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 SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES E::] NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,APID TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME (� Lev—, s DATE (PRINTm a SIGNATURE) �]f')`` LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY#7 93Y TANK# STATE I.D.4 m D I To-F-FolD 1 F D Vy I a PERMIT NUMBER PERMIT APPROVED BYIDATE 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 IN ALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT 79RLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THIVRGROUND STORAGE TANK REGULATIONS FORMS (6.95) ,