COMPLIANCE INFO_1998-2003 - Laserfiche WebLink

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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD d mom, UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. 4L,00 w MARK ONLY ED I NEW PERMIT [D 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ON SITE ONE ITIEM ❑ 2 INTERIM PERMIT F-1 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.IF S. MANUFACTURED BY: C. DATE INSTALLED(MOIDAY/YEAR) ,v&V D. TANK CAPACITY IN GALLONS: Ca 11.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. la REGULAR UNLEADED [] A. I MOTOR VEHICLE FUEL ❑ 4 OIL B. C. F ED 3 DIESEL 6 AVIATION GAS ❑ [2 1b PREMBN UNI EADED 4 GASAHOL 7 METHANOL 2 PETROLEUM ❑ 80 EMPTY lz I PRODUCT Ic MIDGRADE UNLEADED 5 JET FUEL R a mes ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 OTHER(DESCRIBE W MD.BELOM D. IF(A.1)IS HOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.0: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.13,AND C,AND ALL THAT APPLIES IN BOX 0 AND E A. TYPE OF F-1 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ED 5 INTERNAL BLADDER SYSTEM [] 95 UNKNOWN r-7 SYSTEM )4j 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT E] 99 OTHER I BARE STEEL 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK �z MATERIAL 5 CONCRETE 0 POLYVINYL CHLORIDE 7 ALUMINUM ❑ 8 100% METHANOL CCIMPATIBLEWIFRP "My TWO 9 IBRONZE 10 GALVANIZED STEEL ❑ 95 UNKNOWN 99 OTHER C.INTERIOR ❑ I RUBBER LINED ED 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING LINING OR ❑ 5 LINING GLASS 8 UNLINED 95 UNKNOWN 99 OTHER z COATING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES— NO— D.EXTERIOR F-1 I POLYETHYLENE WRAP ED 2 COATING r7 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION 7 99 PROTECTION D 5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN ❑ OTHER SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,etc SPILL TUBE YES NO mm,== STRIKER PLATE YES— NO==— DISPENSER CONTAINMENT YES— NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE A. $YSTEM TYPE A U I SUCTION A PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A I SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND Aj)I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A 5 ALUMINUM A U $ CONCRETE A U 7 STEEL WICOATING A U a l00% METHANOL compA*nsLEw/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK 0 1�=LVf LFAX gg 2 ZXMfM 3 COPITKICIA NTEAMIAL CD 4 BACTRO16C LINE ❑5 AUTOMATIC PUMP ❑ nON MOMTORM LEAK.OETECTOR 94UTOOM 99 OTHER V. LEAK DETECTION ❑ I VISUAL CHECK ❑ 9 MANUAL INVENTORY ❑ 3 VADOZE 4 AUTOMATIC TANK 5 GROUND WATEh 6 ANNUALTANK RECONCILIATION MONITORING GAUGING MONITORING TESTING 7ITORICONTINUOUSNG INTERSTITIAL 8 SIR 9 WEEKLY MANUAL ❑10 MONTHLY TANK MONN 95 UNKNOWN ❑99 01-HER VI.TANK CLOSURE INFORMA71ON(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED OF 3.WAS TANK FILLED WITH E LAST USED(MOIDAYNR) 2.ESTIMATED QUANTITYYES SUBSTANCE REMAINING---A+-- GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNERS NAME DATE (PRWM° T SMATURE) I 22k&4:� arF LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY JURISDICTION# FACILITY# TANK# STATE I.Dl m (_(_®1 = I1 = PERMIT NUMBER PERMIT APPROVED BY/DATE I 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 if FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (645) 0