COMPLIANCE INFO_1986-1999 - Laserfiche WebLink

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PCSOURC,3 C ti STATE OF CALIFORNIA r o' STATE WATER RESOURCES CONTROL BOARD i UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑y PERMANENTLY CLOSEDO� N_SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE LJ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: QU K. 3A-lz)p * /.F V I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK 1.D.# —® B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) 1 -n D. TANK CAPACITY IN GALLONS: C) II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B, CEVla REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ lb PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL EllcMIDGRADE 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.#: 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 ❑ DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM IV 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT El 99 OTHER B. TANK 1?f i 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 ❑ 1 RUBBER LINED ALKYD LINING F-13 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING 6 UNLINED ❑ 95 JdNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES NO— D.EXTERIOR ❑ i POLYETHYLENE WRAP ❑ 2 COATING V95 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION E] 5 CATHODIC PROTECTION ❑ 91 NONE UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL etc. SPILL CONTAINMENT STALLED(YEAR) .-. OVERFLLIIPREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES NO STR K R PLATE YES V 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 1 SUCTION A ru PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION PrU , 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 STE W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U GALVANIZED STEEL A U 10 CATHODIC PROTECTION U 5 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 MECHANICAL UNE LEAK 2 UNE TIGHTNESS 3 CONTINUOUS INTERSTITIAL4 ELECTRONIC LINE 5 AUTOMATIC PUMP ❑ DETECTOR TESTING MONITORING ❑ LEAK DETECTOR [:] SHUTDOWN 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK V RECONCILMANUAL IIATIONORY ❑ 3 MONIITORING VADOZE ❑ 4 AUTOMATGAUGNG IC TANK E] 5 GROUND MONTORINGTER [ET6 ANNUALTESTINGTANK ❑ 7 CONTINUOUSMONITORNG INTERSTITIALSIR ❑ 9 TANEK GAUGINGAL ❑10 TESTING Y TANK ❑ 95 UNKNOWN E] 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMAT D DATE LA T USEkMO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY F JU UK+D D TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME DAT (PRINTED 6 SIGNATURE) NAA__� O*M y4 LOCAL AGENCY USE ONLY ITHE STATE I.D.NUMBER IS'LtMPOSED 0 4E FOUR NUMBERS BELOW STATE LD:# COUNTY# JURISDICTION# FACILITY# TANK# m 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 FORM B (6-95) SHOULD BE ACCOMPANIED BY A PLOT PLVLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE E OUND STORAGE TANK R�ULATIONS q-J3 q XW