COMPLIANCE INFO_1986-1999 - Laserfiche WebLink

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t Er. tg0s C STATE OF CALIFORNIA 'YA••� AP" o, STATE WATER RESOURCES CONTROL BOARD W� � UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B •CSL IFOANI� COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 700 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: au III,Y-1iam .. 111 ��VJJ I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN A OWNER'S TANK 1.D.# „r , B. MANUFACTURED BY: U t4 14–Ivowkj C. DATE INSTALLED(MO/DAYNEAR) , D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. r A. I1 MOTOR VEHICLE FUEL ❑ 4 OIL g, C ❑'to REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS F–] 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 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.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF F–JA DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM (r I 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER 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 COMPATIBLEW/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ ALKYD LINING F–] 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR F–] 5 GLASS LINING U 6 UNLINED ❑ 95 NKNOWN F-199 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YESZNO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING V95 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,etc. SPILL CONTAINMENTINSTALLED(YEAR) OVERFIL7L°PREVENTION EQUIPMENT INSTALLED(YEAR) f DROP TUBE YES s+ NO I R LATE YES V NO DISPENSER CONTAINMENT S NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE 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 A U 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)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STfALWICOATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U„>°9 GALVANIZED STEEL, A U 10 CATHODIC PROTECTION U 5 UNKNOWN A U 99 OTHER - 1 MECHANICAL LINE LEAK 2 UNE TIGHTNESS 3 CONTINUOUS INTERSTITIAL 4 ELECTRONIC UNE 5 AUTOMATIC PUMP D. LEAK DETECTION DETECTOR TEST NG MONITORING LEAK DETECTOR SHUTDOWN ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK MANUAL INVENTORY ❑ 3 VADOZE ❑ 4 AUTOMATIC TANK ❑5 GROUND WATERj'6 ANNUALTANK RECONCILIATION MONITORING GAUGING MONITORING TESTING ❑ 7 CONTINUOUS MONITORING INTERSTITIAL SIR 9WEEKLY TANKGAUGINGAL ❑10 MONTHLY TESTING TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMA DATE LqT SLq(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO 73�aV1 SUBSTANCE REMAINING GALLONS INERT MATERIAL? Ell THIS FORM HAS BEEN COMPLETED UNDER PENALTY F RJU Y,4ND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME DAT (PRINTED b SIGNATURE) �. ln Nn 1 �.:. LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER It.0OMPOSED HE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D:# mI It It 11 It lbil I PERMIT NUMBER PERMIT APPROVED BY/DATE 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 P ILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THERGROUND STORAGE TANK REGULATIONS FORM B (6-95)