COMPLIANCE INFO_1987-2000 - Laserfiche WebLink

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ouaces STATE OF CALIFORNIAPeb...... STATE WATER RESOURCES CONTROL BOARD 0 UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY F-1 I NEW PERMIT F7 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM 0 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT E:] 6 TEMPORARY TANK CLOSURE X's TANK REMOVE DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ztl� elaw )CA`5L�__ I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# 5�: 1 B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAYNEAR) a4l YA--" D. TANK CAPACITY IN GALLONS: 11.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. I MOTOR VEHICLE FUEL F-1 4 OIL B. C. la R 3 DIESEL ,%REGULAR UNLEADED f A. X [_ 6 AVIATION GAS F-] 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT PREMIUM UNLEADED ❑ 4 GASAHOL F__] 7 METHANOL ❑ lc MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 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.It: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,8,AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF ❑ I DOUBLE WALL F-] 3 SINGLE WALL WITH EXTERIOR LINER E] 5 INTERNAL BLADDER SYSTEM Ej 95 UNKNOWN SYSTEM X 2 SINGLE WALL 0 4 SINGLE WALL IN A VAULT 0 99 OTHER B. TANK X 1 BARE STEEL ❑ 2 STAINLESS STEEL E 3 FIBERGLASS F__] 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL F__] 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE F-] 7 ALUMINUM F-] 8 100% METHANOL COMPATIBLEW/FRP (Primary Tank) E] 9 BRONZE ❑ 10 GALVANIZED STEEL [::] 95 UNKNOWN [:] 99 OTHER C.INTERIOR 7 1 RUBBER LINED ❑ 2 ALKYD LINING E] 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR F-1 5 GLASS LINING 1546 UNLINED F-1 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBd WITH 100% METHANOL? YES NO— D.EXTERIOR 0 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP E:] 4 FIBERGLASS REINFORCED PLASTIC CORROSION R PROTECTION E 5 CATHODIC PROTECTION 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER SPILL CONTAINMENT INSTALLED(YEAR) Al 12 OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) �Q!Zij E.SPILL AND OVERFILL,etC- DROP TUBE YES NO '�C STAIKERPLATE YES_ NO DISPENSER CONTAINMENT YES— NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A01 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A a>1 SINGLE WALL A U 2- DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND AG)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 CCMPATIBLEW/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION E]' MECHANICAL UNE LEAK E]2 LINE ❑ TIGHTNESS F-�3 CONTINUOUS INTERSTITIAL 0 4 ELECTRONIC UNE E 5 AUTOMATIC PUMPI. DETECTOR TESTING MONITORING ❑ LEAK DETECTOR ❑ SHUTDOWN 99 OTHER V.TANK LEAK DETECTION El i VISUAL CHECK 2 MANUAL INVENTORYEJ 3 VADOZE F_� 4 AUTOMATIC TANK F_�5 GROUND WATER 6 TETANK RECONCILIATION MONITORING ❑ GAUGING MONITORING TESTING ❑ 7 MONITOROUININTERSTITIAL CONTINUSINI 8 SIR 9 WETANK GAUGIEKLY MANGNUAL E:]10 MOE::] TESTING LY TANK 95 UNKNOWN 99 OTHER G r 4 F-1 VI.TANK CLOSURE INFORM416N(PERMANENT CLOSURE IN-PLACE) 1.ESTIMZTED DATE LAST I)SED(MO/D�!/Yt 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES 0 NO 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.4 FM 10P5k . I 1 / 16 116 5FOIT PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE!—�\ )5/;'lh� THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLEiE6 FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLAjidEILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE GROUND STORAGE TANK REGULATIONS FORM B (6-95) 1p U00 .j