COMPLIANCE INFO_1987-1998 - Laserfiche WebLink

Home Browse Search

ti�.. STATE OF ry �.. t, STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B :w� �►. COMPLETE A SEPARATE FORM FORfEACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ® 5 CHANGE OF INFORMATION ® 7 nRWW4RNTLY CL ITE ONE ITEM ❑I 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ® RE COVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Ei I t -0 11 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK 1.0.s 'j J61 _04, B. MANUFACTURED BY: Ljo C. DATE INSTALLED(MO/DAY/YEAR) LjLoaj;". D. TANK CAPACITY IN GALLONS: i�Inks� n Ii.TANK CONTENTS FA-1ISMARKED.COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C ® la EE DEADE3 DIESEL ❑ 6 AVIATION GAS 4 GASOHOL F72 PETROLEUM F760 EMPTY 1 PRODUCT ® lb PREMIUM ❑ 7 METHANOL ❑ UNLEADED 75 JET L 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 OTHER IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.s: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF L_J i DOUBLE WALL ® 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 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 ❑ 6 100% METHANOL COMPATIBLE W/FRP (PrimwyTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEELeff 95 UNMOWN ❑ 99 OTHER ❑! i RUBBER LINED ❑ 2 ALKYO LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR i 5 GLASS LINING [( 6 UNLINED ❑ LINING 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ D.CORROSION 7711 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 F18ERGLASS REINFORCED PLASTIC PROTECTION ^ 5 CATHODIC PROTECTION LJ 91 NONE 92 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL,PREVENTION EQUIPMENT INSTATED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH FAPPLICABLE A. SYSTEM TYPE A U I SUCTION A 2 PRESSURE A U 3 GRAVITY A U 99 OTHER S. CONSTRUCTION A CX SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 90 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 U 6 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A UNKNOWN A U 99 OTHER D. LEAK DETECTION (Z 1 AUTOMATIC UNE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 0111ASIRIAL MONrORMG ❑99 OTHER V.TANK LEAK DETECTION C 1 VISUAL CHECK 1-7 2 INVENTORY RECONCILIATION ® 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ® 5 GROUND WATER MONITORING A6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 0 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) I 2.ESTIMATED QUANTITY OF I 3.WAS TANK FILLED WITH YES F7NO❑ 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 .e- DATE CLMED 6 S NATURE) i t g LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED FT FOUR NUMBERS BELOW COUNTY 6 JURISDICTION IT FACILITY S TANK>T , STATE I.D.# m C 14 1 -1' PERMIT NUMBER I PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE NZ 142'01:Z THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION.FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WIT 'OCAL AGENCY IMPLEMENTING THE UNDERGROUND STOWE^+E TANK REGULATIONS FORM 6 (12.91) FORM&AII