COMPLIANCE INFO_1998-2002 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARu UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B " COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ) I NEW PERMIT ® 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM `l��-I 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: r I + Zf I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# Gf7/_✓�7 "3 B. MANUFACTURED ✓w --oma- t ►�t C�:ar►i 2i�,r� C. DATE INSTALLED(MO/DAY/YEAR) A D. TANK CAPACITY IN GALLONS: ® D 11.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. to REQ UNLEADED 3 DIESEL ❑ 6 AVIATION GAS F72 PETROLEUM ❑ 80 EMPTY 1 PRODUCT tb UNLEADED 4 GASAHOL ❑ 7 METHANOL ®. 3 CHEMICAL PRODUCT ❑ 85 UNKNOWN ❑ 2 WASTE ® 2 LEADED U!W EADED U 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S. 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.8,AND c.AND ALL THAT APPLIES N BOX D AND E A. TYPE OF 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL MADDER SYSTEM ® 95 UNKNOWN SYSTEM ❑y 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 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 ❑ 8 100% METHANOL COMPATIBLE WIFRP ( *nM T-k) ❑ 9 BRONZE ® 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED n 2 ALKYD LINING ® 3 EPDXY LINING ® 4 PHENOLIC LINING; LINING OR ❑ 5 GLASS LINING 6 UNLINED ® 95 UNKNOWN ❑ 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 UNKNOWN ❑ 99 OTHER -- LE.SPILL AND OVERFILL,etc. SPILL CONTAINMENT I STALLED(YEAR) OVERFILL REVENTION EQUIPMENT INSTALLED(YEAR) 1 a a DROP TUBE YES NO STRIKER PLATE YES n 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 A 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER S. CONSTRUCTION A U 1 SINGLE WALL A 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U N 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 8 100% METHANOL COMPATIBLE W/FR PROTECTION A U 8 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN ATUU 99 oTHER nexi 41 nc n-"MVt�'^!G D. LEAK DETECTION Imcm ' 'W ❑21UNE 3 MOMTOFM ❑TWmfm 4 IIEC�LMEmaom= 5 WrOMAIM KW mmxm ❑99 oTNER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL RECONCILIATIONRY ❑ 3 MONITORING VADOZE 4 GAUGINGAUTOMATITANK E]5 GROUND WATER ®6 ANNUAL NG TESTING 7 CONTINUOUS MONITORINGINTERSTITIAL ❑ 8 SIR ❑ 9 TANK AUGINGA ❑10 MONTHLY TANK ❑ 95 UNKNOWN ®0 OTHER STIN V1.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2 ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ® NO EDSUBSTANCE REMAINING GALLONS INERT MATERIAL 7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNERS NAME� c, (^c„T;TM� ® DATE (PRINTED&SIGNATURE) Owner LOCAL AGENCY USE ONLY THE STATE LD. UMBFIS CPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE LD:# Com❑ I I I I I-T] I I I 1—T-7 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPUCA71ON-FORM A,UNLESS A CURRENT FORM A HAS BEEN FLED. FORM UST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLAN THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UN OUND STORAGE TANK REGULATIONS FORM B (695)