COMPLIANCE INFO_1984-2002 - Laserfiche WebLink

Home Browse Search

• RwC.3 CO STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD 3y ......` UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B •C�t+FOR N+� 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 ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 5-rola *12--t I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN p Y A. OWNER'S TANK I.D.# I Z1 —3 B. MANUFACTURED BY: X C. DATE INSTALLED(MO/DAY/YEAR) )q 85 D. TANK CAPACITY IN GALLONS: /0/000 II.TANK,90NTENTS IF A-1 IS MARKED,COMPLETE ITEM C. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. 1.REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS A ❑ 2 PETROLEUM ❑ 80 EMPTY �/ PRODUCT ❑ ib PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 1c MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 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.#: III. TANK CONSTRUCTION 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 ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ i BARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100! METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR RUBBER LINED ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING� 1 ❑ ❑ LINING OR ❑ 5 GLASS LINING 6 UNLINED ❑ 95 NKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ( ❑95 UNKNOW ❑ 99 OTHER E.SPILL AND OVERFILL CtC. SPILL CONTAINMENT STALLED(YEAR) OVERFILL P VENTION EQUIPMENT INSTALLED(YEAR) + DROP TUBE YES NO STRIKER PLATE YES 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 U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A(6_) 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)Ao 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 CATHODZ! ROTECTION A U 95 UNKNOWN U 99 OTHER D. LEAK DETECTION1 MECHANICAL UNE LEAK 2 LINE TIGHTNESSE�j 3 CONTINUOUS INTERSTITIAL 4 ELECTRONIC LINE 5 AUTOMATIC PUMP ❑ DETECTOR [:jTESTING MONITORING ❑ LEAK DETECTOR SHUTDOWN ❑ 99 OTHER V.TANK LEAK DETECTION WVISUAL CHECK ❑ 2 MANUALRECONCINVENTORY ❑ 3 VAATION O ORING 4 GAULA IC TANK ❑ 5MONND W TER ❑6 ANNUAGTANK MONITORING INTERSTITIAL ❑ 8 SIR ❑ 9 WEEK LY MANUAL ❑10 MONTHLY TANK ❑ 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAY/YR) A1 j 2.ESTIMATED QUANTITY OF3.WAS TANK FILLED WITH YES I—I Nn n SUBSTANCE REMAINING -----GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER P A TYX PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME DAT (PRINTED B SIGNATURE) /IA/1/_� LOCAL AGENCY USE ONLY THE STATER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.4 m PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT f FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THERGROUND STORAGE TANK REGULATIONS FORM B (6-95)