COMPLIANCE INFO_1998-2004 - Laserfiche WebLink

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0 0 ✓! 1 , g.SRC�S C STATE OF CALIFORNIA +� STATE WATER RESOURCES CONTROL BOARD ; UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B •CSI IfpR M,f. 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 ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Jos" i E-=iT! 1 �I��Ll 1. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN A. OWNER'S TANK 1.D.# ro Z B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) & D. TANK CAPACITY IN GALLONS: / 11.TANK CO TENTS IF A-1 IS MARKED,COMPLETE ITEM C. A1 MOTOR VEHICLE FUEL F__] 4 OIL g. C. ❑ 1 GULAR UNLEADED F-13 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY i PRODUCT tbPREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ Ic MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN E] 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(Ai)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: III. TANK CONSTRUqy0N 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 SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W1 FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100' METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 LKYD LIVING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING 6UNLINED ❑ 95 UN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE E]95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL etc. SPILL CONTAINMENT IN LED(YEAR) OVERFILL P ENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES NO STRIKER PLATE YES NO DISPENSE CONTAINMENT YES NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U i SUCTION 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A 0 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) GFIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PR TECTIONA U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ME—'CAL UNE LEAK 2 UNE TIGHTNESS COfTINUCUS NTERSTMAL4 ELECTRONIC UNE 5 ALRCVA"PUMP ❑ 99 arrfER CETECTCR TESTING IdONTORNG ❑ LEAK o£TECTCR ❑ SHUTCCwl( V.TANK LEAK DETECTION ❑ 1 SUAL CHECK ❑ 2 MANUAL RECO CILNTEO ORY F__] 3 MON TORING VADOE ❑ 4 GAUL NG1C TANK ❑5 MON TORINGROUND TER ❑ 6 TESTINGTANK MONITORING G INTERSTITIAL E] 8 SIR ❑ 9 WEEK LY MANUAL ❑10 TESTING Y TANK F--] 95 UNKNOWN ❑ 99 OTHER VI,TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAYNR) I 2.ESTIMATED QUANTITY OF I 3.WAS TANK FILLED WITH YES ❑ NO ElSUBSTANCE REMAINING GALLONS INERT MATERIAL 7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAIk� DATE (PRINTED S SIGNATURE) n P I _ J!"tAS 1/LI LOSI�i 2 �CS C � LOCAL AGENCY USE ONLY THE STATE I.D,NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D:# W FT= 1-77-1 1 -1 1 PER:'IT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATICN DATE "4!S FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORA C FAUST 27-COMPLE1 ED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPAMED SY A PLOT PI LE:TI.11S FORM WITH THE LOCAL AGENCY IMPLEMENTING THE U uROUR D STORAGE TANK REGULATIONS