COMPLIANCE INFO_1988-2004 - Laserfiche WebLink

Home Browse Search

0 �g,oURCts STATE OF CALIFORNIA c STATE WATER RESOURCES CONTROL BOARD o lb UNDERGROUND STORAGE TANK PERMIT APPLICATION FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. 5 CHANGE OF INFORMATION E:l 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT '>S 6 TEMPORARY TANK CLOSURE F-1 8 TANK REMOVED MARK ONLY F-1 1 NEW PERMIT E::] 3 RENEWAL PERMIT F-1 F DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK 1.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: 11.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. 777- A- >94�1 MOTOR VEHICLE FUEL F-1 4 OIL B. C. ❑ la REGULAR UNLEADED 0 3 DIESEL F-] 6 AVIATION GAS �l PRODUCT b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL 71 2 PETROLEUM E] 80 EMPTY "I lic MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 [:] 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELONG D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF '�:59 I DOUBLE WALL F__j 3 SINGLE WALL WITH EXTERIOR LINER F-1 5 INTERNAL BLADDER SYSTEM F-] 95 UNKNOWN SYSTEM F-1 2 SINGLE WALL F-1 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ I BARE STEEL 3 FIBERGLASS 2 STAINLESS STEEL 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC ,K MATERIAL F-] 5 CONCRETE F__] 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLEW/FRP (Primary Tank) ❑ 9 BRONZE 0 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED F-1 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING E:] 6 UNLINED E__1 95 UNKNOWN 99 OTHER/:��/L>-yr COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? Y0b� NO r__N D.EXTERIOR El 1 POLYETHYLENE WRAP ❑ 2 COATING El 3 VINYL WRAP F7 4 FIBERGLASS REINFORCED PLASTIC CORROSION v;p� PROTECTION E] 5 CATHODIC PROTECTION 0 91 NONE 4?,Qae E:l 95 UNKNOWN oTN 99 OTHER SPILL CONTAINMEXT INSTALLED(YEAR)I I OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) 7 E.SPILL AND OVERFILL,etC- DROP TUBE Y NO STRIKER PLATE YES X I 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 100 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U I SINGLE WALL A U 2 DOUBLE WALL 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 p 99 OTHER D. LEAK DETECTION ❑ MECHANICAL UNE LEAK [::]2 LINE TIGHTNESS �TINUOUS INTERSTITIAL J�CTDRff UNE -ALruromAwnc Pump ..N" tEAK DETECTOR Epe SHUTDOWN H TDO N ❑ DETECTOR, ❑ TESTING MONITORING 99 OTHER V.TANK LEAK DETECTION UAL CHECK ❑ 2 MANUAL INVENTORY ❑ 3 VADOZE ❑ 4 AUTOMATIC TANK ❑5 GROUND WATER ❑ 6 ANNUALTANKI F-1�1�s E:J RECONCILIATION MONITORING F-1 GAUGING MONITORING F_� TESTI G ERI 7 MONITORING CONT]NUOUS INTERSTITIAL 0 8 SIR ❑ 9 WETANK EKLY MANUALE]10 MOTESTING NTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER GAUGING 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 YESNO I SUBSTANCE REMAINING ---GALLONS I INERT MATERIAL? Ej ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTED&SIGNATURE) -LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK STATE I.Dl m FTTI I I I I I I 1 111 Lf 10 11110 17 1��?3 PERMIT NUMBER PERMIT APPRr)vr-n BY/DATE I PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APP -FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. 0 C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A 131_0 11E THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING GROUND STORAGE TANK REGULATIONS FORM B (6-95) mw