COMPLIANCE INFO_1987-2000 - Laserfiche WebLink

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STATE OF CALIFORNIA ...... roti STATE WATER RESOURCES CONTROL BOARD 3 0 UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY F-1 I NEW PERMIT F_j 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE ONE ITEM El 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: dw - I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN 7-7 A. OWNER'S TANK I.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: 11.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A- 1 MOTOR VEHICLE FUEL r__j 4 OIL B. C. ❑ to REGULAR UNLEADED ]�<3 DIESEL ❑ 6 AVIATION GAS x ❑ lb PREMIUM UNLEADED 1::]-4 GASAHOL F7 7 METHANOL ❑ 2 PETROLEUM El 80 EMPTY X, PRODUCT El 1c MIDGRADE UNLEADED [-] 5 JET FUEL F] 8 M85 [:] 3 CHEMICAL PRODUCT Ej 95 UNKNOWN El 2 WASTE ❑ 2 LEADED El 99 OTHER(DESCRIBE IN ITEM 0.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 E-1 4 SINGLE WALL IN A VAULT ❑ 99 OTHER 'yk B. TANK xi BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL F-] 5 CONCRETE 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM E] 8 100% METHANOL COMPATIBLEW/FRP (Primary Tank) D 9 BRONZE E] 10 GALVANIZED STEEL ❑ 95 UNKNOWN 0 99 OTHER 1 RUBBER LINED 2 ALKYD LINING F ] 3 EPDXY LINING ❑f__j 4 PHENOLIC LINING C.INTERIOR F7 LINING OR ❑ 5 GLASS LININGP6 UNLINED F__j 95 UNKNOWN F-1 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 1001/6 METHANOL? YES_Z_\NO D.EXTERIOR F__] 1 POLYETHYLENE WRAP O 2 COATING F-1 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION F__195 UNKNOWN ❑ 99 OTHER PROTECTION 1:15 CATHODIC PROTECTION 91 NONE E A 0 yel SPILL CONTAINMENT INSTALL EAR) jjjj_ft_ OVERFILL PREVENTION. M _ VQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,etC- DROP TUBE YES._... ...... No STICKER PLATE YES_ NO DISPENSER CONTAINMENT'YESO�_ NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE v SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION Ao SINGLE WALL A U 2- DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A(D 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 STEEL WICOATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION E 1 MECHANICAL LINE LEAK0 2 UNE TIGHTNESS F7 3 CONTINUOUS INTERSTITIAL []4 ELECTRONIC UNE E 5 AUTOMATIC PUMP 99 OTHER DETECTOR TESTING ❑ MONITORING ❑ LUX DETECTOR ❑ SHUTDOWN V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL INVENTVADOZE ❑ 4 AUTOMATGROUND WAANUAL RECONCILIATIONORY ❑ 3 MONITORING F-1 GAUGINGIC TANK ❑ 5 MONITORINGTER ❑6 TESTINGNTANK E] 7 MONITCONTINUOORING INTERSTITIAL 8 SIR US 9 WEEK KLY MANUAL 10 MOTESNTTIHLYG TANK ❑ 95 UNKNOWN ❑ 99 OTHER x GAUGING E] N VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 9.ESTIMATED 'E LAST SED R) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES [] NO F-NI ;a Gf SUBSTANCE REMAINING f9::_7GALLONS INERT MATERIAL 7 L/ch- 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) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW P R_ COUNTY# JURISDICTION# FACILITY# TANK# STATE 01 101 a 131 1 v 161615 PERMIT NUMBER PERMIT APPROVED BY/DATE kj JPERMIT 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 FORM 8 (6-95)SHOULD BE ACCOMPANIED BY A PLOT PILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THEJORGROUND STORAGE TANK REGULATIONS y