COMPLIANCE INFO_1995-1999 - Laserfiche WebLink

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�yov�cty STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B `i COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO IT ONE ITEM F72 INTERIM PERMIT f74 AMENDED PERMIT F76 TEMPORARY TANK CLOSURE El TANK REMOVED I DBA OR FACILITY NAME WHERE TANK IS INSTALLED: P,tG Ro 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN G C 4 OWNER'S TANK I.D.# Z B. MANUFACTURED BY: XERX�^S C. DATE INSTALLED(MO/DAYNEAR) Z 15 q9 Ct) I D. TANK CAPACITY IN GALLONS: 110, 000 II TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A. Cg 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ to REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL F7 2 PETROLEUM ❑ 80 EMPTY t PRODUCT f171 tc MIOGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 1❑� 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM 0.BELOW) 0. 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 0 AND E A. TYPE OF }bl 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR UNER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 89 OTHER B. TANK ❑ 1 BARE STEEL- ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W1 FIBERGLASS REINFORCED PLASTIC 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 UNING ❑ 4 PHENOLIC LINING LINING OR F7 5 GLASS LINING 29 6 UNLINED F795 UNKNOWN F799 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 ❑ ❑ 91 NONE n 95 UNKNOWN El 99 OTHER PROTECTION 5 CATHODIC PROTECTION ,_, E.SPILL AND OVERFILL,etc. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES—L4— NO STRIKER PI ATE YES 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 A O 2 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)A 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U B 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑1 ME..UNE LEAK ❑2 UNE TIGTNE HSS X71 3 CONTINUOUS INTERSTMAL �4 ELECTRONIC UNE IG 5 AWOMATIC PUMP 17 99 OTHER OEMCTOR TESTING id MOMTORING LEAK DETECTOR 1� SNUTOOWN U V.TANK LEAK DETECTIONGROUND1 ❑ 1 VISUAL CHECK ❑ 2 RECONCiLIAT10NORY ❑ 3 MONOITORING `4 GAUGING AUTOMATIC TANK ❑ 5 MONITORINGTER ❑6STINANNUAL MANUAL GTANK 7 MONITORING INTERSTITIAL ❑ 8 SIR ❑ 9 WEEK LY MANUAL ❑ 10 MONTHLY TANK 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) MIA 1.ESTIMATED DATE LAST USED(MO/DAYNR) I 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO❑ SUBSTANCE REMAINING GALLONS I INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK e200101 S NAME LA (67 DATE / n (PRINTED 6 SIGNATURE) CAL tA LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW I COUNTY# JURISDICTION# FACILITY#37,2- TANK# 0107 STATE I.DJ m � � 3 ( b I . 151c) 1 Y1 31 M7 7 6 9y PERMIT NUMBER PERMIT APPROVED BY/OATE PERMIT EXPIRATION DATE i THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLIC IN-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FO'-'C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PL jWTHIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE'0GROUND STORAGE TANK REGULATIONS FORMS (6-95)