COMPLIANCE INFO_1997-2002 - Laserfiche WebLink

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• � • 'ty wwca.c STATE OF CALIFORNIA �� r STATE WATER RESOURCES CONTROL BOARD i r UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B •C�11.OI+N++'. COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS ON TE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED O DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 4p-at;, '4M PM e/Q 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.1J B. MANUFACTURED BY: XE�� C. DATE INSTALLED(MO/DAYNEAR) zip, D. TANK CAPACITY IN GALLONS: 11.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A 0 1 MOTOR VEHICLE FUEL ❑ 4 OILg, C. 1a REGULAR UNLEADED E] 3 DIESEL ❑ 6 AVIATION GAS ❑ lb PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ is MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE E] 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELom D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.M 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 Efri 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 p LINING OR F-1I•'U �� 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100°.6 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 E.SPILL AND OVERFILL etc. SPILL CONTAINMENT I TALLED(YEAR) OVERFILL P EVENTION EQUIPMENT INSTALLED(YEAR) + DROP TUBE YES NO STRIKER PLATE YES NO DISPENSER CONTAINMENT YES NO IV.PIPING INFORMATION CIRCLE A IF ABOVE a UND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U i SUCTION A&04 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL 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)ANA 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 D. LEAK DETECTION 1 MECHAMCAL UNE LEAK2 UNE 11GWNISS COPMNU s KM;Sn uu f'`''' ELECTROM0 UNE AUTOMATIC PUMP DmcTOR a TESTING MOMTORING J=X LEMC DETECTOR SHUTDOWN ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 MANUAL�5RECONCILIATIONINVENTORY ❑ 3 MONIITORING OZE ❑ 4 GAUGING AUTOMATIC TANK ❑5 GROUND MONITORING TESTING 7 MON TOR NG INTERSTITIAL El SIR ❑ 9 WEEK LY MGAUGANUAL E]10 MONTHLY TANK ❑ 95 UNKNOWN ❑99 OTHER TESTIN VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 YES E:] NO❑ THIS FORM HAS BEEN CO ED UNDER PEN LTY F PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAMDAT (PRINTED 6 SIGNATURE) -4 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# QO STATE I.D.4 1510 1(P I PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE Ilp 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 INSTALLA ONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PJVLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THERGROUND STORAGE TANK REGULATIONS FORM B (6-95)