COMPLIANCE INFO_2000-2005 - Laserfiche WebLink

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�µyam' A,7,1', p7`a"�„�"' `:'�`H_._.p., -'•3 O STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD W , 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 ❑ 7 PERMANENTLY CLOS 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: (�LFr m k S No S40 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK 1.D.# B. MANUFACTURED BY: Mo de-,K LjP '';' C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: OO 0 IL TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A_ ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C ❑ to REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT lb PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 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.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 1 DOUBLE WALL F__] 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM F] 95 UNKNOWN SYSTEM ❑ 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 ❑ 2 ALKYD LINING F__] 3 EPDXY LINING [:] 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO_ D.EXTERIOR 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER SPILL CONTAINMENT INSTALLED(YEAR) OVERFIJ�PREVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,@t0. DROP TUBE YES sg. 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 AID 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL AQ 2 DOUBLE WAIL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER y 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 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER ❑ v 1 MEC14ANICAL LINE LEAK 2 LINE TIGHTNESS 3 CONTINUOUS INTERSTITIAL 4 ELECTRONIC LINE 5 AUTOMATIC PUMP 99 OTHER D. LEAK DETECTION DETECTOR TESTING MONITORING LEAK DETECTOR SHUTDOWN ❑ V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUALINVENTORECONCILIATIONRY ❑ 3 VADOZE MONITORING El AUTOMATGAUGING MONITORING TANK ❑ 5 GROUND MONITORINGTER El ANNUALTESTINGTANK ❑' 7 MONITORCONTINUOUS INTERSTITIAL E::] 8 SIR ❑ 9 WEEK LY MANUAL E:]10 MONTESTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 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 A SIGNATURE) Z,�L_ 2—.3—. /�p LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW C" 2 5--50 COUNTY# JURISDICTION;t FACILITY# TANK# .. STATE I.D:# ( m PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE AR L THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICAT N•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOR MUST BE COMPLETED FOR INSTALLATIONS.T IS FORM SHOULD BE ACCOMPANIED BY A PLOT PLAWE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE U jWROUND STORAGE TANKGU TION'AS(� FORM B (6-95) , { D