COMPLIANCE INFO_2002-2010 - Laserfiche WebLink

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a � C STATE OF CAUFORMA t, STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B �db� a: . +�i . • COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. Cil lwpw M`. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PRMI ❑ 8 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED I � cOVA / DBA OR FACILITY NAME WHERE TANK IS INSTALLED: VAd c, 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.A _ B. MANUFACTURED BY: = S C. DATE INSTALLED(MO/DAY/YEAR) C D. TANK CAPACITY IN GALLONS: c o II.TANKCONTENTS IFA-I IS MARKED,COMPLETE ITEM C. I•REGULAR 3 DIESEL A De'l MOTOR VEHICLE FUEL ❑ 4 OIL e. C. L^ UNLEADED E] 8 AVIATIONGAS ❑ 2 PETROLEUM ❑ 80 EMPTY / PRODUCT EDtb PREMIUM 4 GASAHOL E] 7 METHANOL ❑ ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ UNLEADED 5 JET FUEL ❑2 WASTE 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.I)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED y C.A.S.s: III, TANK CONSTTR,RUUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF ENT", DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER 8. TANK F-] 1 BARE STEEL ❑ 2 STAINLESS STEEL E] 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PTimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR .❑ 5 GLASS LINING ls�r6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100*/. METHANOL 7 YES_)e'-'No_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U I SUCTION Ao 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U I SINGLE WALL A@2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)Ao 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER - ----- --- RTERSTRQ D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR LD2 LINE TIGHTNESS TESTING MONRORING ❑99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK INVENTORY RECONCILIATION F-13 VADOZE MONITORING EYf4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING I _J 6 TANK TESTING V7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH ES ❑ NO❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL?�l/ THIS FORM HAS BEEN CO PL TE NDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NA?,IE DAIE /�y..p y (PRINTED 8 SIGNA7 RE) 7 //- LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW l COUNTY# JURISDICTION# FACILITY 8 TANK it STATE I.D.# F I A13 ' p (o 13111,151 PERMIT NUMBER tp O PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE D THIS FORM MUST BE ACCO IED BY A PERMIT APPLICATION•FORM A,UNLESS A C NT FORM A HAS BEEN FILED. FILE THIS FORM WITHIWCAL AGENCY IMPLEMENTING THE UNDERGROUND qw E TANK REGULATIONS FORM 9 (12.91) - -ia- v 1