COMPLIANCE INFO_1986-1999 - Laserfiche WebLink

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is -CQs STATE OF CALIFORNIA 0 A• """" i STATE WATER RESOURCES CONTROL BOARD Y mom, 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 F-1L 6 TEMPORARY TANK CLOSURE r l 9 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK 1.D.s 2n—0-2— 1 B. MANUFACTURED BY: t N`L C. DATE INSTALLED(MOIDAY/YEAR) Is D. TANK CAPACITY IN GALLONS: 11.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C, 1 UNLEADED3 DIESEL ❑ 6 AVIATION GAS F-12 PETROLEUM E] 80 EMPTY 1 PRODUCT ib PREMIUM UNLEADED 4 GASAHOL ❑ 7 METHANOL ❑ lc MIDORADE UNLEADED 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE E] 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C.AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF ❑ 11 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ® 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM L_�Q 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 COMPATIBLE W/FRP (Pr)maryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING U 6 UNLINED ❑ X95 UU KNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES V NO— D.EXTERIORF-11 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 INYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION [:] 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL 6tC. SPILL CONTAINMENT I TALLED(YEAR) VERFI P ELATION EQUIPMENT INSTALLED(YEAR) + DROP TUBE YES NO STRIKER PLATE YES 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 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 i 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 8 CONCRETE A U 7 STE W/COATING A U B 100%METHANOL ATIBLEW/FRP PROTECTION A U Z GALVANIZED STEEL 0,6 U 10 CATHODIC PROTECTION U 5 UNKNOWN A U 99 OTHER AVOW CAL UNE LEAK 2 UNE MffWSA 3 CCM NTFASMAL 4 ELEC MIC L 5 AUTOMATIC PI D. LEAK DETECTION DETECTOR TESTNG ❑ MONTOFM ❑ LFAK DETECTOR sHumovm ❑99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK M/2 MANUAL INVENTORY ❑ 3 VADOZE MON ❑ 4 AUTOMATICAUTANK ❑5 GROUND WATER 6 ANNUALTANK MONITOR) TESTING ❑ 7 CONTINUOUS'INTERSTITIAL B SIR ❑ 9 WEEKLY MANUAL ❑10 MONTHLY TANK ❑ 95 UNIOVOWN"} ❑ 99 OTHER MONITANK lug TESTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOsuRE IN-PLAcE) 1.ESTIMATED DATE LAU USEINMO/DAY/YR) 2 ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH C� SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 "` YES NO THIS FORM HAS BEEN COMPLETED UNDER PENALTYqF PE UR ,A TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME -.,... $, (PRM11E0 b SKU+IATURE) rT- LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER SED OF FOUR NUMBERS BELOW t COUNTY A,. "JURISDICTION N FACILITY b TANK# ,,,, STATE I.D# FF'"T-1 I I 177 -I I I I PERMIT NUMBER PERMIT APPROVED BYIDATIE 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 WTALLAT(ONS.,THIS FORM SHOULD BE ACCOMPANIED BY A PLOT P LE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE IldWEAGROUND STORAGE TANK REGULATION FORM B (6.95)