COMPLIANCE INFO_1989-1998 - Laserfiche WebLink

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uRce. STATE OF CALIFORNIA 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 F-]❑ 5 CHANGE OF INFORMATION C. DATE INSTALLED(MO/DAY/YEAR) May, yg proposed 7 PERMANENTLY CLOSED ON SITE ONE ITEM ED2 INTERIM PERMIT F-1 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED 41 rl DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Waterloo Liquor D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. # ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS I. TANK DESCRIPTION COMPLETE ALL ITEMS - SPECIFY IF UNKNOWN A. OWNER'S TANK 1. D. # B. MANUFACTURED BY: 7 In d C. DATE INSTALLED(MO/DAY/YEAR) May, yg proposed D. TANK CAPACITY IN GALLONS: 15 000 II. TANK CONTENTS IF A-1 IS MARKED, COMPLETE ITEM C. A. __j 1 MOTOR VEHICLE FUEL ❑ 4 OIL 80 EMPTY B. 56 1 PRODUCT C. ❑ 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ SYSTEM ❑ 1c MIDGRADE 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 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 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 ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING F�Rj 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES X NO— D. EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP F:;4 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E. SPILL AND OVERFILL, BtC. SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) Ln DROP TUBE YES NO STRIKER PLATE YES X NO DISPENSER CONTAINMENT YES NO IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE A 1 SUCTION A 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND CORROSION PROTECTION A U A U A U 1 BARE STEEL 5 ALUMINUM 9 GALVANIZED STEEL A U A U A U 2 STAINLESS STEEL A U 6 CONCRETE A U 10 CATHODIC PROTECTION 3 POLYVINYL CHLORIDE (PVC) AU 4 FIBERGLASS PIPE 7 STEEL W/ COATING A 8 100% METHANOL COMPATIBLE W/FRP A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION El 1 MECHANICAL UNE LEAK [7 DETECTOR 2 UNE TIGHTNESS 3 CONTINUOUS INTERSTRIAL 4 ELECTRONIC LINEin TESTING MONITORING LEAK DETECTOR 5 AUTOMATIC PUMP SHUTDOWN ❑ 99 OTHER V. TANK LEAK DETECTION (❑ 1 VISUAL CHECK ❑ 2 MANUAL ECONCILIATIONORY ❑ 3 VAOZE MONIITORING ❑ 4 AUTOMATGAUGING MONITORING TANK E]5 GROUND MONITORINGTER ❑ 6 TETANK STING `-' 7 MONITORCONTINUOUS [:]8 SIR ❑ 9 WEETANKLY MANUAL ❑ 10 MOTESTINGHLY TANK E]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 I 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 a SIGNATURE) Heng Chea 17 Aril 9 8 LOCAL AGENCY USE ONLY THE STATE I.D. N B IS C POSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # TANK # STATE I.Dl m 0 1 7 PERMIT NUMBER I PERMIT APPROVED BY/DATE I PERMIT EXPIRATION DATE , , , ./ _ ( _'-7 THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION -FORMA, UNLESS A CURRENT FORMA HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLkTION$. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THEWRGROUND STORAGE TANK REGULATIONS FORM B (6-95)