COMPLIANCE INFO_1998-2004 - Laserfiche WebLink

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w s STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM 8 •��I,IOw M+' COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT [D--3---RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT O 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE El 0 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# 00 3 B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) ✓v � 3?& D. TANK CAPACITY IN GALLONS: II.TANK CO TENTS IF A-1 IS MARKED,COMPLETE ITEM C. p 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ to REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS F 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ lbEMIUM UNLEADED ❑ 4 GASAHOL E] 7 METHANOL 1c MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOM D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.# Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C,AND ALL THAT APPUES IN BOX D AND E A. TYPE OF i DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER Q 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER 11 B. TANK ❑ 1 BARE STEEL 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W/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 ❑ i RUBBER LINEDn�jZUNUNED KYD LINING � 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR O 5 GLASS LINING ❑ 95 UN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES NO— D.EXTERIOR a 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOW ❑ 99 OTHER E.SPILL AND OVERFILL etc. DRILL CONTAINMENT INS LLED(YEAR) OVERFILL P ENTION 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 APPUCABLE A. SYSTEM TYPE A U 1 SUCTION A U PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL ACU 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEL 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 0 100% METHANOL COMPATIBLE WlFRP PROTECTION A U 9 QACVANIZED STEEL A U 10 CATHODIC OTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION cHunral LINE LEAx ❑2 UNE TGHTNESS 3 CONTINUOUS WTERSTmAL 4 ELECTRONIC LINE O 5 AUTOMATIC PUMP GETEaoA TESTING MOPATORING VAX DETECTOR SHUMOwN ❑ 99 01NER V.TANK LEAK DETECTION ❑ 1 ISUAL CHECK ❑ 2 MANUAL RECONCILIATION ORY ❑7 3 MAODO MONITORING ❑ 4 AUTOMATGAUGING MONITORING TANK ❑5 MONTORINGWATER ❑ 6NGTANK 7 MON TORWG INTERSTITIAL ❑ 8 SIR LJ g WEEKLY GAUGANGAL ❑ 10 TESTI MONTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAY/YR) ( 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 YES ❑ NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAM DATE (PRINTED b S1GNdTURE) '-- r /. LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# _ TANK# STATE I.D.# m I j PER.VIT NUMBER I PERMIT APPROVED BY/OATE PERMIT EXPIRATION DATE ' ::SFORM, 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 FLAN, FILE THS FORM WITH THE LOCAL AGENCY PAPLEMENT1NG THE UNDERGROUND STORAGE TANK REGULATIONS 0