COMPLIANCE INFO_1995-2004 - Laserfiche WebLink

Home Browse Search

Y' Uq.p STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD u o UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B �,�, 0 s . . 9COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY a 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY C TE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE nZ8 TANK REMOVE DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Jc I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKN WN A. OWNER'S TANK I.D.8 B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) Y D. TANK CAPACITY IN GALLONS: V II.TANKC NTENTS IFA-1 IS MARKED,COMPLETE ITEM C. Ai MOTOR VEHICLE FUEL ❑ 4 OIL B. Li/ C. a REGULAR 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY PRODUCT ❑ 1b PREMIUM ❑UNLEADED 4 GASAHOL ❑ 7 METHANOL UNLEADED ❑ 5 JET FUEL ❑ 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.A III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,13,AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF ❑ DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL [:] 3 FIBERGLASS F-14 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE 07 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE O 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING VE] 3 OXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR F-] 5 GLASS LINING ❑ 6 UNLINED NKNOWN99 OTHER LINING ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION 0 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR)ULMVIA))lOVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR)a�d�ilUl IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A 1 SINGLE WALL A U 2 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)A U 4 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 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION [_] 1 AUTOMATIC LINE LEAK DETECTOR [—] 2 LINE TIGHTNESS TESTING 3 INTE A OTHER MONITORING V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE5 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1. TIMATE DTE LAST U D,MOND YNR)j! 2.ESTIMATED SUBSTANCE QUANTITY EMAN NGF GALLONS 3.WAS TANINERFILLEDMATERIWITH YES �OF THS FORM HAS BEEN C►OMPLET fEGD UND NA F P U TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLI ANTS NAME UR 4�" (PRI T N DATE C� LOCAL AGENCY USE ONLY THE STATE I.D.NUMBERi�o6mPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# �Q I STATE I.D.# m I I a PERMITNUMBER PERMIT APPROVED BY/DATE PERM IT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILECU FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (12-91) 0• FOR00348-R6