COMPLIANCE INFO_1997-2002 - Laserfiche WebLink

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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 ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: k)'u0 �AC 3•-t-I I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN A. OWNER'S TANK 1.D.K , I B. MANUFACTURED BY: Xe C. DATE INSTALLED(MO/DAY/YEAR) d 1�$ G� D. TANK CAPACITY IN GALLONS: 12C> 0 U V II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL S. C. to REGULAR UNLEADED ❑ 3 DIESEL ❑ 8 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ib PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ to MIDGRADE UNLEADED5 JETFUEL 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ F__199 OTHER(DESCRIBE IN(TEM D.BELOM D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.N III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX D AND E j7 A. TYPE OF J" i 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 K3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ® 8 100:6 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 �8 UNLINED ® 95 UNKNOWN E:] 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100°1. METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ® 3 VINYL WRAP fb;�'4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,etc. SPILL CONTAINMENT IN TALLED(YEAR) OVERFILL PgEVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES NO STRIKER PLATE YES V 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 U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL ACU2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U i 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 8 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 1 MECHANICAL LINE LEAK2 UNE TIGHTNESS 3 CONTNUOIB INTERSTITIAL (�4 ELECTRONIC UNE 5.,AUTOMATIC PUMP D. LEAK DETECTION ED a TESTING MONITORING �A+ LEAK DETECTOR SHUTDOWN ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL RECONCILIATIONORY ❑ 3 MONITORING ❑ 4 GAUGING AUTOMATIC TANK ❑5 GROUND MONITORING TER r78 TANK STING 7 CONMON INUOU INTERSTITIAL ❑ 8 SIR ED WEEK LY MANUAL ®10 TESTILY 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 SUBSTANCE REMAINING GALLONS I INERT MATERIAL? YES [—] NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND T THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME DATE A (PANTED b SIGNATURE) \ `� \�- 10\ � � 1 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMP SED OF THE FOUR NUM RS BE OW COUNTY 0 JURISDICTION It FACILI If TANK 0 STATE I.D.4 m F TT� I I I 1- 11 1 1 PERMIT NUMBER PERMIT APPROVED BY/OATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLI ON-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FO M C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THFORGROUND STORAGE YANK REGULATIONS FORMS (8.95)