COMPLIANCE INFO_1985-1998 - Laserfiche WebLink

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fyOURCtJ ,: STATE OF CALIFORNIA A� `° `o r .4 STATE WATER RESOURCES CONTROL BOARD ; g -UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B - C�IIIORN� j. COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY / NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED j DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Waterloo O E j I ., I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN Y A OWNER'S TANK 1.D.# B. MANUFACTURED BY: loo ern Welding C. DATE INSTALLED(MOIDAYNEAR) 12798 D. TANK CAPACITY IN GALLONS: I t oupf k II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. F k f7 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. _, to REGULAR UNLEADED ❑ 3.DIESEL `-.6 AVIATION GAS ❑ ❑ 11 PREMIUM UNLEADED ❑ 4 GASAHOL_.❑ 7 METHANOL 2 PETROLEUM ❑ 80 EMPTY F-1 1 PRODUCT ❑ 1c MIDGRADE UNLEADED ❑ 5 JETFUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 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 ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 9 FIBERGLASS ❑ 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 ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 1001/6 METHANOL? YES= NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL �0, SPILL CONTAINMENT INSTALLED(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 i SUCTION AL02 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U / SINGLE WALL AW2 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 U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A L{ 8 100% METFI� CJkT1(a , PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A�t 99 OTHER �+ D. LEAK DETECTION 1 MECHANICAL LINE LEAK 2 LINE TIGHTNESS ❑3 CONTINUOUS INTERSTITIAL 4 ELECTRONIC UNE 5 AUTOMATIC PUMP DETECTOR ❑ TESTING MONITORING ❑ LEAK DETECTOR ❑ SHUTDOWN ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL RECONCILNTEONNORY ❑ 3 MONIITORING VAOZE 4 GAUL NG AUTOMATIC TANK ❑ 5 MON TORINGGROUND TER F-16 TESTINGTANK E] 7 CONTINUOUS MONITORING INTERSTITIAL ❑ 8 SIR ❑ 9 TANEK WEKGLY ❑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.WASTANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES ❑, NO _s THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY AND TO THgBET—OFIMY KNOWLSOGE,IS,TpUE.AlVD E:OARECt TANK OWNER'S NAME (PRINTED 6 SIGNATURE) Keith eith A• l l J.a—A +".':pV/Gp f n Q LOCAL AGENCY USE ONLY .THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY#`: TANK# STATE I.D:# 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 PLOLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THEROUND STORAGE TANK REGULATIONS FORM 8 (6-95) t 7C AA