COMPLIANCE INFO_1986-2002 - Laserfiche WebLink

Home Browse Search

NM#A 0 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 ❑ 6 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: r 11gyaw I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# © B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) 1 nab-i D. TANK CAPACITY IN GALLONS: Q II.TANK ONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. It EV 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. 0 la REGUL R 6 AVIATION GAS ❑ 3 DIESEL ❑ A. E:12 PETROLEUM F780 EMPTY 1 PRODUCT E:] lb PREMIUM 4 GASAHOL ❑ 7 METHANOL F—] 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE E:] V 2 LEADED UNLEADED V JOTHER ET L(DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED l e C.A.S.#: III. TANK CONSTRVCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C.AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF 1 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 ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM E 100% METHANOL COM ATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL [:] 95 UNKNOWN 99 OTHER a v F—] 1 RUBBER LINED ❑ 2 ALKYD LINING F-1 EPDXY LINING F—] 4 PHENOLIC LINING C.INTERIOR LINING F—]L 5 GLASS LINING ❑ 6 UNLINED 95 UNKNO ��,W"❑ 99 OTHER �M w ISING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ KY\ D.CORROSIONFq 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVE G ND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION p U2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U2 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 cu FIBERGLASS PIPE CORROSION A Up ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A tr 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION p U 95 UNKNO N A U 99 OTHER D. LEAK DETECTION V 1 AUTOMATIC LINE LEAK DETECTOR [::] 2 LINE TIGHTNESS TESTING 3 INTERSTITIAL MONITORING ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING F—] 6 TANK TESTING LV 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE IBM COU NTY# JURISDICTION# tFACILITY#;kli TANK# PERMIT NUMBER PERMIT APPROVED BY/DATE PERMITEXPI TI NDATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORMA,UNLESS A CURRENT FORMA HAS BEEN FILED. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS 1 FORM (12-91) • �-�'S�S��'� 4FOR0034B.R6