COMPLIANCE INFO_1989-1998 - Laserfiche WebLink

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�"{i ,,ounces STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD W� , UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B o Cit lfpn N.� COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED O ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED I DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN i A OWNER'S TANK I.D.# B. MANUFACTURED BY: 'r I C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: AQ 4 II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. 1 MOTOR VEHICLE FUEL ❑ 4 OIL g, C ❑�-,-} to REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS j PETROLEUM ❑ 80 EMPTY ❑, 1 PRODUCT IBJ1-fib PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ tc MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 j ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN El2 WASTE ❑ 2 LEADED ED 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 I A. TYPE OF F–] 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM —] 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER I B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS E:] 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC f w 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 ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER f 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 91 NONE 95 UNKNOWN 99 OTHER j PROTECTION ❑ 5 CATHODIC PROTECTION [1] ❑ ❑ r SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,etc. DROP TUBE YES NO STRIKER PLATE YES NO DISPENSER CONTAINMENT YES NO t IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE F k A. SYSTEM TYPE A U 1 SUCTION A 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION AG 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,1 j 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE i CORROSION A l7`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 D. LEAK DETECTION R I MECHANICAL LINE LEAK ❑2 LINE TIGHTNESS ❑3 CONTINUOUS INTERSTITIAL [D4 ELECTRONIC LINE ❑5 AUTOMATIC PUMP ❑ 99 OTHER ❑. DETECTOR TESTING MONITORING LEAK DETECTOR SHUTDOWN V.TANK LEAK DETECTION 2 MANUAL INVENTORY ❑ 3 VADOZE El4 AUTOMATIC TANK ❑5 GROUND WATER`❑6 ANNUALTANK El VISUAL CHECK RECONCILIATION MONITORING GAUGING MONITORING TESTING ❑ 7 CONTINUOUS INTERSTITIAL ❑ 8 SIR ❑ 9 WEEKLY MANUAL ❑10 MONTHLY TANK ❑ 95 UNKNOWN E] 99 OTHER MONITORING TANK GAUGING TESTING f! VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) i 1.ESTIMATED DATE LAST USED(MO/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 OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME DATE {, (PRINTED 6 SIGNATURE) It LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW E COUNTY# JURISDICTION# FACILITY# TANK# STATE I.Dl PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION LIATE t 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 f FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING T DERGROUND STORAGE TANK REGULATIONS FORM B (6-95) q-#- 9 ? y