COMPLIANCE INFO_1998-2006 - Laserfiche WebLink

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tyouRC3 CO STATE OF CALIFORNIA ...... STATE WATER RESOURCES CONTROL BOARD 0 UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B a COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT E 3 RENEWAL PERMIT F-] 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT F-] 4 AMENDED PERMIT F-] 6 TEMPORARY TANK CLOSURE F-1 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 2 7'7 1 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: 11.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. k_-H] I MOTOR VEHICLE FUEL ❑ 4 OIL B. C. E] to REGULAR UNLEADED F-1 3 DIESEL f_-] 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT 0 lb PREMIUM UNLEADED F-] 4 GASAHOL 0 7 METHANOL F j ic MIDGRADE UNLEADED F__] 5 JET FUEL Ej 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 0 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 APPLIES IN BOX D AND E A. TYPE OF I DOUBLE WALL F-] 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL F__1 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK F__] 1 BARE STEEL ❑ 2 STAINLESS STEEL E:j 3 FIBERGLASS F7 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE F__j 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) E 9 BRONZE [:] 10 GALVANIZED STEEL 0 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED � 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— D.EXTERIOR D 1 POLYETHYLENE WRAP ❑ 2 COATING El 3 VINYL WRAP F-1 4 FIBERGLASS REINFORCED PLASTIC CORROSION Ej 5 PROTECTION PROTECTION ❑ CATHODIC PRoTc _]F 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER N SPILL CONTAINMEVT INSTALLED(YEAR) OVGASI�L PREVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,etDROP TUBE YES _N_ NO STRIKER PLATE YES '4 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 I SUCTION A U 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)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELWICOATING A U 8 100% METHANOL COMPATIBLEW/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 sr._ODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION E]1 MECHANICAL LINE LEAK [:]2 LINE TIGHTNESS 3 CONTINUOUS INTERSTITIAL r---1 4 ELECTRONIC LINEF-�,❑5 AUTOMATIC PUMP DETECTOR TESTING MONITORING L-J 'LEAK DETECTOR SHUTDOWNE-] 99 OTHER V.TANK LEAK DETECTION R 0 1 VISUAL CHECK 0 2 RECONCILIMANUAL INATIONE]VENTORY ❑ 3 MONITORING VAOZE 0 4 MO GAUGING AUTOMATIC TANK 0 5 GROUNDNITORING TEWATER ANSTING 6 NUAL TANK _ 7 CONTINUOUS INTERSTITIAL Ej 8 SIR ❑ 9 WEEK EKLY MANUAL E]10 MOTESTINTHLY TANK F-] 95 UNKNOWN ❑ 99 OTHER MONITORING TAGAUGING NG 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 YES I SUBSTANCE REMAINING —GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTED&SIGNATURE) I LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# [---- STATE I.D.1 ol c- L I Z 15 Ir'-') l 10 1 Z� 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 01111k FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THIORGROUND STORAGE TANK REGULATIONS FORM 8 (6-95) w