COMPLIANCE INFO_1985-1998 - Laserfiche WebLink

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'so�Rces �..'. STATE OF CALIFORNIA A� " "• oo �' STATE WATER RESOURCES CONTROL BOARD ; UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B ,I •O�IIROR+`+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 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Waterloo Food & Fuel P4 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN i A OWNER'S TANK I.D.# B. MANUFACTURED BY: moctern weiclifig C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: 8,000 IL TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. YH REGULAR UNLEADED ❑ 3 DIESEL 6 AVIATION GAS A. ❑ 1 MOTOR VEHICLE FUEL E] 4 OIL B. C. ❑ 2 PETROLEUM F--] 80 EMPTY 1 PRODUCT 1b F PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL 1c MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT El 95 UNKNOWN 1:12 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(Ai)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 F-13 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER a B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FI$ER _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 ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100°/6 METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE E:]95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL etc. SPILL CONTAINMENT INSTALLED(YEAR) OVERPR FILL EVENTION EQUIPMENT INSTALLED(YEAR) + C. 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 e 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 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 AU 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A 8 100% M ANOL.COM BLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN ATU-'99 OTHER ` ` D. LEAK DETECTION 1 MECHANICAL UNE LEAK( 2 LINE TIGHTNESS 3 CONTINUOUS INTERSTITIAL 4 ELECTRONIC LINE 5 AUTOMATIC PUMP LEA DETECTOR ❑ E]TESTING MONITORING ❑ K DETECTOR ❑ SHUTDOWN ❑'99 OTHER V.TANK LEAK DETECTION NUAL EQ 1 VISUAL CHECK ❑ 2 RECONCILIATIONMANUALINVENTORY F--] 3 MONIITORING OZE 4 GAUGING AUTOMATIC TANK ❑5 MONITORINGGROUND WATER E::]6 TESTINGTANK EA 7 CONTINUOUS MONITORING INTERSTITIAL ❑ 8 SIR E:]9 MEKGLY AUGANUAL ❑10 MONTHLY 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 YES ❑ NO❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? 7H/8 FORM HAS BEEN COMPLETED UNDER PENALTY OFPE5JdRyATOTEST l3WLEDGE,IS TRUE AND.C1E7RftET TANK OWNER'S NAME DATE T�,�?1c I a 3I $-* t3 10/24/9 (PRINTED B SIGNATURE) �- I'Tg- , .. LOCAL AGENCY WE ONLY THE STATE I.D.NUMBER IS COMPOSED t#THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK STATE LD:# m-lTTI I I 1– 1` PERMIT NUMBER 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 INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT P LE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE GROUND STORAGE TANK REGULATIONS FORMS (6-95) -