COMPLIANCE INFO_1985-1998 - Laserfiche WebLink

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souAces STATE OF CALIFORNIA .""` '°"•• °o t STATE WATER RESOURCES CONTROL BOARD 3 g UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED ' DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Ft.4M6- L I a()O(Zs ,J I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# 3 B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) SP2i `q q6 D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A. 5;;�1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C ❑ 1a REGULAR UNLEADED 3 DIESEL ❑ 6 AVIATION GAS ❑ ❑ 2 PETROLEUM 80 EMPTY �1 PRODUCT lb PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ ❑ ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 1c MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ B M85 El2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOM 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 ❑ 95 UNKNOWN SYSTEM �❑!2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT F-] 99 OTHER B. TANK ILEI + BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS O 4 STEEL CLAD W/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 LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ®6 UNLINED a 95 UNKNOWN F-199 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 1` PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ' ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL etc. SPILL CONTAINME T STALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) + DROP TUBE YES NO STRIKER PLATE 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 Alt 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A 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)AD 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 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION D31MECHANICAL LINE LEAK 2 LINE TIGHTNESS 3 CONTINUOUS INTERSTITIAL 4 ELECTRONIC UNE5 AUTOMATIC PUMP ❑ DETECTOR ❑ TESTING MONITORING ❑ LEAK DETECTOR SHUTDOWN 99 OTHER V.TANK LEAK DETECTION CHECK ❑ 2 ECONCILIATIONMANUAL ORY ❑ 3 VADOZE MONITORING 4 AUTOMATGAUGING IC TANK ❑5 GROUNDWAMONITORING TER ❑ 6 ANNUAL TESTING W7VISUAL MONITORING INTERSTITIAL ❑ 8 SIR ❑ 9 WEEK LY MANUAL E:]10 MOST HLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAYNR)� A 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH n C SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PE TY OF RJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTED&SIGNATURE) /✓ L r_ LOCAL AGENCY USE ONLYTHESTATE I. .NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW (� COUNTY# JURISDICTION# FACILITY# TANK# STATE I.DJ m FT-T-I o -7 v 1 PERMIT NUMBER 3�U 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 INS ALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THEOPRGROUND STORAGE TANK REGULATIONS FORM B (6-95)