COMPLIANCE INFO_1998-2004 - Laserfiche WebLink

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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD ; UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B •C�I.I Ow Mir COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT [?--3-'RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT F__j 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 OWNER'S TANK I.D.# /'1 B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) (/�LD. TANK CAPACITY IN GALLONS: If.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C to REGULAR UNLEADED E] 3 DIESEL ❑ 6 AVIATION GAS 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ lb PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ID lc MIDGRADE UNLEADED ❑ 5 JETFUEL ❑ 8 M85 O 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 F__j 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 ❑ i BARE STEEL 2 STAINLESS STEEL3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE O 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100.5 METHANOL COMPATIBLE WlFRP (Primary Tank) ❑ 9 BRONZE 0 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER I RUBBER LINED 2 A KYD LINING 3 EPDXY LINING 4 PHENOLIC LINING C.INTERIOR o � ❑ ❑ LINING OR ❑ 5 GLASS LINING 6 UNLINED ❑ 95LINK WN F199 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 166% 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 .11 Zp E.SPILL AND OVERFILL @4C. SPILL CONTAINMENT IN LLED(YEAR) OVERFILL.PENTION 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 1 SUCTION A I 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A 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' FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A"T 8 100/6 METHANOL COMPATIBLEW/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION "ECIWOCAL LINE LEAK2 CINE TIGHTNESS CONTINUOUS INTERSTITIAL 4 ELECTRONIC UNE s auroRurc Fuca OETECiOR a TESTING MONITORING CEAK CRECTOR SMJTDCY,V 99 OTHER V.TANK LEAK DETECTION ❑ NUAL 1 UAL CHECK ED2 MANUAL INVENTRECONCILIATIONORy ❑ 3 MONIITORING VAOZE ❑ 4 GAUD NGAUTOMATIC TANK E]5 MON TORINGTEA ❑ 6 TESTINGTANK 7 MON TORO G INTERSTITIAL ❑ 8 SIR E] 9 TANEK GA AUG ❑10 M NT LY TANK E] 95 UNKNOWN El 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MOIDAYNR) ( 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS I INERT MATERIAL 7 YES E:] NO E] THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOW/LEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PgINTED b SiGNATURI -'�`— �- LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELO°! COUNTY# JURISDICTION# FACILITY# TANK# I STATE LD.# I� 77-1 PERMIT NUMBER PERMIT APPROVED BYIDATE I PERMIT EXPIRATION DATE FORA FAUST BE ACCOMPANIED BY A PERMIT APPL9CA, N-FO9M A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOP. FAUST BE COMPLETED FOR INSTALLATIONS. THIS FCF:':4 SHOULD BE ACCOMPANIED BY A PLOT PLA E T}tiS FORM N/TH T}iE LOCAL AGENCY IMPLEMENTING THE UROUND STORAGE TANK REGULATIONS