COMPLIANCE INFO_2002-2010 - Laserfiche WebLink

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STATE OF CALIFORNIA ; •• , STATE WATER RESOURCES CONTROL BOARD r Acb, UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B 0 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT �] 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT C] 6 TEMPORARY TANK CLOSURE ❑ / TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 0 ` d 0A I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK 1.D.0 U iq B. MANUFACTURED BY: v C V C. DATE INSTALLED(MO/DAY/YEAR) 1� OCT 0. TANK CAPACITY IN GALLONS: �p f II.TANKCONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. hIS 1 G� 1 c 0)ov aj 1 �I+ 1 A i MOTD VEHICLE FUEL ❑ 4 OIL W C. ❑ la REGULAR 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 .PETROLEUM ❑ 80 EMPTY 1 PRODUCT (R� lb PREMIUM 4 GASAHOL ❑ 7 METHANOL UNLEADED 5 JET FUEL 0 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED H 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.a: y/41 UI. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C.AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF I; DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER 8. TANK El /' BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 100% METHANPL COMPATIBLE W/FRP (PrimaryTmk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1.. RUBBER LINED ❑ ALKYD LINING ❑ 3 EPDXY LINING E::] 4 PHENOLIC LINING C.INTERIOP F-15 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL 7 YES-ZNO_ D.CORROSION ❑ !. POLYETHYLENE WRAP ❑ 2 COATING El POLYETHYLENE VINYL WRAP 4 FIBERGLASS 9FINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) < <` OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR)j IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE • A. SYSTEM TYPE ' U 1 SUCTION A 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION ' U 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) U 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 AU 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION � AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING MONRORING ❑ 99 OTHER V.TANK LEAK DETECTION �I 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING BZ"4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING C� 6 TANK TESTING t�/7 INTERSTITIAL MONITORING ❑ 91 NONE 0 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAYNA) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN CO ETA UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DAT /�. (PRINTED A SIGNAT 1 e LOCAL AGENCY USE ONLY THE TATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION N FACILITY M TANK 8 O0 STATE I.D.# m 3 l © (- 12 Z (o PERMIT NUMBER �� PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE 10171q& cc>nr�R t�z 4�t THIS FORM MUST BE ACCSI IED BY A PERMIT APPLICATION•FORM A,UNLESS A gfi.7,ENT FORM A HAS BF,EN FI Y e.;k Fq_F THh rngnA W Of!AI.AGFNCY IMP[.FMFNTING THE UNDERGROUN E TANK REGULATION