COMPLIANCE INFO_1986-1999 - Laserfiche WebLink

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• • g puwCt$ STATE OF CALIFORNIA +��'""• `Oi STATE WATER RESOURCES CONTROL BOARD 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 ❑ 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: Q Y-. 3M 4-- '?F) I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK 1.D.# ® B. MANUFACTURED BY: V rl�4_f,..5C>jj C. DATE INSTALLED(MO/DAYNEAR) , 2 D. TANK CAPACITY IN GALLONS: ITANK CONTENTS IF A•1 IS MARKED,COM— PLETE ITEM C. to REGULAR UNLEADED 3 DIESEL 6 AVIATION GAS A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL g. � C. ❑ ❑ ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ ib PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 1c MIOGRADE UNLEADED E::] 5 JET FUEL F-] 8 M85 E:] 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 F-] 95 UNKNOWN SYSTEM V2 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 COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR 711 RUBBER LINED ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR 7 5 GLASS LINING 6 UNLINED ❑ 95 KNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES NO_ 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 CONTAINMENT STALLED(YEAR) OVERFILIIPREVENTION EQUIPMENT INSTALLED(YEAR) It DROP TUBE YES NO STRIKER 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 3 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION U 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 1 MECHANICAL UHT NE LEAK 2 LINE TIGNESS 3 CONTINUOUS INTERSTITIAL4 ELECTRONIC UNE 5 AUTOMATIC PUMP D. LEAK DETECTION OETECTOR TESTING MONITORING ❑ LEAK DETECTOR E] SHUTDOWN ❑ 99 OTHER V.TANK LEAK DETECTION ❑ i VISUAL CHECK ❑ MANUAL RECONCILIATION INVENTORY ❑ 3 MAONNIITORING O 4 GAUGING IC TANK AUTOMATE] 5 MON TORINGGROUND WATER 6 ANNUAL ❑ 7 MON TORIONG J INTERSTITIAL - a SIR ❑ g TV%EKLY GAUGINGAL ❑10 MOTESTINGHLY TANK E] 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ES-nMATgD DATE I T USElkjMO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY F*JUF,,fAPD TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME DAT (PRINTED 6 SIGNATURE) NA LOCAL AGENCY USE ONLY g THESTATEI.D.NUMBER I MPOSED 0 E FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.4 m I 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 PLA`" LE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE U' RGROUND STORAGE TANK REGULATIONS FORM B (6.95)