COMPLIANCE INFO_1986-2001 - Laserfiche WebLink

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* 0 P`gOV RC.s C STATE OF CALIFORNIA ." o STATE WATER RESOURCES CONTROL BOARD 3 UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B W m 0 'i •OSI IROR H,r• 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 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED I j Lf DBA OR FACILITY NAME WHERE TANK IS INSTALLED: QU�� STo(� �� J �' I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# -76—f B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) -lTv f/6 19918 D. TANK CAPACITY IN GALLONS: 'Z p 0 O II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C to REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 11 PREMIUM UNLEADED ❑ 4 GASAHOL � 7 METHANOL ❑ 1c MIDGRADE UNLEADED ❑ 5 JETFUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 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 ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL EZ/3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ g BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR 1 RUBBER LINED ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ff 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES v NO_ D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP E�f4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION El 5 CATHODIC PROTECTION ❑ 91 NONE ❑�alR 95 UNKNOWN ❑ 99 OTHER / etc. SPILL CONTAINMENT I TALLED(YEAR) OVERFILL REVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL 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 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U i SINGLE WALL A U 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)A4 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODI PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 MECHANICAL LINE LEAK D 2 LINE TIGHTNESS En 3 CONTINUOUS INTERSTITIAL 4 ELECTRONIC LINE 5 AUTOMATIC PUMP ❑ 99 OTHER DETECTOR TESTING MONITORING LEAK DETECTOR SHUTDOWN V.TANK LEAK DETECTION ❑ VISUAL CHECK ❑ 2 RECONCIMANUAL LIATION NTORY F-] 3 MONITORING VADOZE4 GAUGINAUTOMATG TANK ❑5 MONTORINGGROUND TER ❑ 6 TESTING ANNUAL7 CONTINUOUS TANK MONITORING INTERSTITIAL ❑ 8 SIR ❑ 9 TANEKLY KGAUGING MANUAL A GIINGAL ❑ 10 TESTING Y TANK F-1g5 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAYNR) N/r- 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ^ SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER P NAL RJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME DATE i (PRINTED 8 SIGNATURE) ^A(„-cC p,2- �C0� qf1) LOCAL AGENCY USE ONLY THE STATE L BER IS COMPOSED OF THE FOUR NUMBERS BELOW \c'G J D `�G C COUNTY# JURISDICTION# FACILITY# TANK# C� V STATE 101 FM D IWITEU PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE (L l THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLIC N-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORALC MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PL LE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE JWGROUND STORAGE TANK REGULATIONS FORM 8 (6.95)