COMPLIANCE INFO_1997-2002 - Laserfiche WebLink

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tsa"acta STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD s UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B •��i�rowM•►. COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED 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: ,4RrO /540-/1-17y/fp. -rAle v �� I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK 1.D.# z B. MANUFACTURED BY: 9C'E'zi � C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL a 4 OIL B. C. ❑ to REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ��b PREMIUM UNLEADED ❑ 4 GASAHOL E::] 7 METHANOL ❑ 2 PETROLEUM F-1 80 EMPTY 1 PRODUCT ❑ tc 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 FM'l DOUBLE WALL O 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 O 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE 6 POLYVINYL CHLORIDE r_� 7 ALUMINUM F-] 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 R�r99 OTHER 1-1-A/p COATING IS LINING MATERIAL COMPATIBLE WITH 1009/6 METHANOL? YESX NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 2r04 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL etc. SPILL CONTAINMENT I STALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES NO STRIKER PLATE YES-,KL 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 A U 1 SINGLE WALL A 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)Ad> 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 MECHANIGIL UNE LEAK 2 UNE TIGHTNESS CONTINUOUS WMRSTRiAI I,SECrnawc UNE f5�13 AuroMAnc auGP ❑ ❑ OETECTOR ❑ TESTING MONITORING (L� LEAK DETECTOR 1� SHUTDOWN 99 OTHER V.TANK LEAK DETECTION {❑ 1 VISUAL CHECK 2 MANUAL INVENTORY NO ❑ 4 AUTOMATIC TANK WATER ANNUAL TANK RECONCILIATION MONITORING GAUGING MONITORING G J� 7 CONTINUOUS UINTERSTITIAL ❑ 8 SIR ❑ 9ELYMA ❑10 MONTHLY TANK ❑ 95 UNKNOWN E-]99 OTHER K NGSL VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 6 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF [_3T;W;AS�T�ANK FILLED WITHSUBSTANCE REMAINING GALLONS RT MATERIAL? YES ❑ NO❑ THIS FORM HAS BEEN CgMalitD UNDER PEjyfY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NDATE,,/,1�./ !{ y��` TANK 8 SjGNATU P, ��TT44•• C7 /�+`�!� LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY#' 3 TANK# ®d STATE I.D.4 m o PERMIT NUMBER 77rPERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE p 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 PJVLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THESRGROUND STORAGE TANK REGULATIONS FORM B (6-95)