COMPLIANCE INFO_1996-2006 - Laserfiche WebLink

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>` STATE OF CALIFORNIA * o� STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B tl° -' COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. 3 RENEWAL PERMIT �❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY C MARK ONLY 711 NEW PERMIT ❑ ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ® 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: irloo Food I. TANK DESCRIPTION COMPLETE ALL ITEMS–SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# B. MANUFACTURED BY: Unknown C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: 5,000 II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. q ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL ❑B. C to REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ib PREMIUM UNL ❑'"4 GASAFIOL ❑ 7 METHA14 _ x + ❑ 2 PETROLEUM ❑ 80 EMPTY 4 PRODUCT ❑ Ic MIDGRADE UNLEADED 5 JET FUEL ❑ 8 M85 r 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 WASTE ❑ 2 LEADED 99 OTHER(DESCRIBE IN ITEM D.B"M D. IF(A 1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED Lead'e ('xa$Ql i ne' C.A.S.# III. TAI (C-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 z SYSTEM ® 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER I B. TANK 1 BARE STEEL ' ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC E MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLEW/FRP 9 (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 El5 GLASS LINING ❑ 8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER C 1 COATING , IS LINING MATERIAL COMPATIBLE WITH 100°/6 METHANOL?I' ?' `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 etSPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTI UIPMENT INSTALLED(YEAR) iXUlle + c. DROP TUBE YES NO STRIKER PLATE.YES NO DISPENSER CONTAINMENT YES NO IV.PIPING INFORMAT N CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPEA 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER Q' 't B. CONSTRUCTION A . 1 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)A U 4 FIBERGLASS PIPE CORROSION A 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U'-S 100% METHANOL COMPATIBLE W/FRP PROTECTION A 9 GALVANIZED RFEELA.0 10 CATHODIC PROTECTION A U 95 UNKNOWNA U '99 OTHER + ' �. LEAK DETECTION 1 MECHANICAL UNE LEW 2 LINE TIGHTNESS 3 CONTINUOUS INTERSTITIAL 4 ELECTRONIC LINE $:AUTOMATIC PUMP DETECTOR ❑ TESTING ❑ MONITORING ❑- MAL DETECTOR SHUTDOWN ❑ 99 OTHER V.TANK LEAK DETECTION h 6 ANNUALTANK ❑ i VISUAL CHECK ❑ RECONCILIATION �❑ MONITORING ❑ GAUGING ❑ MONITORING 2 MANUAL INVENTORY 3 VADOZE 4 AUTOMATIC TANK 5 GROUND WATER ❑ TESTING { h ❑ 7 MONITORCONTINUU INTERSTITIAL ❑ '8 SIR ❑9 WEEK LY MANUAL ❑10 MONTNHLL�Y 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 iti 0 WAS TANK FILLED WITH YES ❑ I�SUBSTANCE REMAINING V GALLONT3_ INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, ND fJ TSET MY KNOWLEDGE,fS TRU£AND CORRECT TANK OWNER'S NAME p(PRINTED d SIGNATURE) {elth A, dailic!" 2C � �f Sf'f3 :9 9 - �= LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTYA JURISDICTION# FACILITY# TANK;#. STATE I.D.# ❑❑ PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE - THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPL ON•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS:-TIN FOFM1- SHOULD BE ACCOMPANIED BY A PLOT FWLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THro RGROUND STORAGE TANK REGULATIONS FORM B (69