COMPLIANCE INFO_1997-2002 - Laserfiche WebLink

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6sW1.Gt STATE OF CALIFORNIA .p 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 Q 3 RENEWAL PERMIT Q 5 CHANGE OF INFORMATION Q 7 PERMANENTLY CLOSED ON SITE ONE ITEM 2 INTERIM PERMIT ® 4 AMENDED PERMIT Q 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 3 , I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I.O.0 3.. B. MANUFACTURED BY: Q S D.TANK CAPACITY IN GALLONS: C. DATE INSTALLED(MGWAY/YEAR) . ,.'b t;,,t . 11.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. 22 UUU g�. UST to REGULAR UNLEADED ' 3 DIESEL 6 AVIATION GAS A l MOTOR VEHICLE FUEL ® 4 OIL B C • _ ._ . .,. 9b PREIANM UNLEADED 4 GASAHOL � 7 METHANOL Q 2 PETROLEUM - ® BO EMPTY -f- 1_PRODUCT , , -+ -_. n tc MmGRADE UNLEADED 5"JET FUEL 8 M85 ® 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ® 2 WASTE 2 LEADED 99 OTHER IDESCRGE IN REM 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 1 DOUBLE WALL `❑ 3 SINGLE WALL WITH EXTERIOR LINER Q S BYIERNAL BLAD�R SYSTEM ® 95 UNKNOWN A.TYPE OF ._.. .•.,,;.. ,. ,C. , ,. , .; :.. p .- . . SYSTEM ❑ 2 SINGLE WALL Q 4 SINGLE,WALL N A VAULT r.. .' Q 99 OTHER B. TANK ❑ 1 BARE STEEL E] 2 STAINLESS STEEL �3 FIBERGLASS Q 4 STEEL CLAD,W/FIBERGLASS REINFORCED PLASTIC MATERIAL ® 5 CONCRETE Q 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100%METHANOL(COMPATIBLE W(FRP (PrknY TonW ❑ 9 BRONZE ❑ 10 GALVANIZEDr STEEL Q 95 UNKNOWN ® 99 OTHER . . ; ❑ 1 •RUBBER LINED ® 2 ALKYD LINING ® 3 EPDXY LINING•• Q 4 PHENOLIC C.INTERIOR ¢ Z x . s. -T LINING OR a LINING UNUNED 95"UNKNOWN 99 OTHER 5 .LASS 2`..,® _. ❑ u ,. - .. COATINGIS*LINING MATERIAL COMPATIBLE WITH 100%METHANOL? .�,t.YES_ NO—: n . :.�. D.EXTERIOR Q 1 POLY-M- MLENE WRAP ❑ 2 COATING'-- ®+3 VINYL WRAP FIBERGLASS REINFORCED PLASTIC CORROSION f- I r^ .^ _� PROTECTION :.❑ S CATHODIC PROTECTION Q ®/ NONE r ❑95 UNKNOWN v ❑ 99 OTHER . SPILL CONTAINMENT I�IrDTALLED(YEAR) - OVERFILLf EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,etc. DROP TUBE YES Q_ NO STRIKER PLATE YES •' NO ' DISPENSER CONTAINMENT YES NO IV.PIPING INFORMATION~ CIRCLEFA 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 Ac—U)2'DOUBLE WALE'` 'A'U -3 LINED TRENCH A'U''95 UNKNOWN A U 99 OTHER C. MATERIALA U / BARE STEEL A U 2 STAINLESS STEEL`A U 3 POLYVINYL CHLORIDE(PVC)AG4 FIBERGLASS PIPE CORROSION A U 8 ALUMINUM A U 8 CONCRETE rr 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 [:]' oeauwuL LRS LEAK ®2 LINE T*ffN S 3 CRERSMK a=MONC UK 5 AirtaweTIC MW ❑99 OTHER oETEcroR TEmm M ONTORM mox am-a w wimosm V.TANK LEAK DETECTION a Q / VISUAL CHECK ❑ _2. RECONCILUAL IATION MONITORING 3 MONITORING VADOZE ® 4 GAUGING TANK ❑ . GROUND WATER MONITORING ❑® TESTING 7 MONITORING UODUS INTERSTITIAL ❑ 8 SIR Q 9 TWEEKLYANK 2A MANUAL Q 10 MONTHLY TANK ❑ 95 UNKNOWN Q 99 OTHER WING MUNG VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE N•PLACE) 1.ESTIMATED DATE LAST USED(MOIDAY/YR) 2.ESTIMATED QUANTITY OF3.WAS TANK FILLED WITH YES Q NO❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL T THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNERS NAME DATE `' G (PRWTEDASIGNATURE) L b -1 LOCAL AGENCY USE ONLY THE STATE LD.NUMBER IS C POSED OF THE FOUR NUMBVS BELOW COUNTY! JURISDICTIONN FACILI ME TANK aY STATE I.D.1 m = PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN BLED.FORM C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOW FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM 5 (6.95)