COMPLIANCE INFO_1993-1994 - Laserfiche WebLink

Home Browse Search

a STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B �,� , 10,s COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 ERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 ANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: -73-70 I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# 1 B. MANUFACTURED C. DATE INSTALLED(MO/DAY/YEAR) 11-70 D. TANK CAPA IN AL S: 00 D ILTANKCONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. laUNLEAD R ❑ 3 DIESEL ❑ A. 6 AVIATION GAS 2 PETROLEUM ❑ 80 EMPTY 1 PRODUC lb PREMIUM ❑ 4 GASAHO ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 A E UNLEADED ❑ A—JETFUEL ❑ 2 LEADED ❑ gg TH%9 SCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C,A # III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B, ALL THAT APPLIES IN BOX D AND E A. TYPE OF F—] 1 DOUBLE WALL ❑ 3 SINGLE W'' W ERIOR LINER ❑ 95 UNKN SYSTEM 2 SINGLE WALL E:] 4 SECONDARY TAINMENT (VAULTED T ❑ 99 OT B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERG STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6PO INYL CHLORI E ❑ 7 ALUMINUM THANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 LVANIZED STEEL ❑ 95 UNKNOWN ❑ ❑ 1 RUBBER LINED ❑ AL D LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC 1 C.INTERIOR ❑ 5 GLASS LINING 6 UNL ED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPAT ILE THANOL? YES NO D.CORROSION ❑ 1 POLYETHYLENE WRAP 2_CTING ❑ 3 L RAP ❑ 4 FIBERGLASS R IPO ASTIC PROTECTION � 5 CATHODIC PROTECTION 1 N NE ❑95 ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CON ENT INS ALLED(YEAR) RFIL P ENTION EOUI ENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCL A IF OV GROUNDOR U IF DERGR THIFAPPL A. SYSTEM TYPE A U 1 SUCTION PRESSUR 3 GRAVITY I A Vil 99 OTHER B. CONSTRUCTION A El SINGLE WALL A:U 2 DOLlpf kA41 'U 3 LINED TR A b 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U BARE STEEL "A U 2 STA L E L A U 3 POLYVINYL HL IDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A 6 CO A U 7 TEEL W/ TING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A 10 CAT IC PROTECTION AA "OWN A U 99 OTHER INT D. LEAK DETECTION Q 1 AUTOMATIC LINE LEAK DETECTOR LINE TIGHTNE S ❑ 3 MONRORING ❑ 99 OTHER 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 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION -3+3 1.ESTIMATEDATE LAST SED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO 1 P —7 3 SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND C RRECT APPLICANTS NAME r DATE (PRINTED 8 SIGNATURE) f LOCAL AGENCY USE ONLY THE ST TE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBER OW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# 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. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (12-91) 0 0 FOR0034B-R6