COMPLIANCE INFO_1987-1998 - Laserfiche WebLink

Home Browse Search

s :. STATE OF CALIFORMM WATER RESOURCES CON L BOARD f� FORM `B': UN ERGROUND STORAGE TANK PROGRAM " TANK TANK PERMIT APPLICATION INFORMATION ° COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. ��[f0 NSP MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM FR 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED Q FACILITY/SITE NAME WHERE TANK IS INSTALLED: 12 f FARM TANK -YES ❑ NO I. TANK. DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY A. OWNERS TANK ID # B. MANUFACTURED BY: f.L C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: Il. TANK CONTENTS IF (A.1). IS MARKED. COMPLETE ITEM C. IF (A.11- IS NOT MARKED. COMPLETE ITEM D -- A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY [::] 95 UNKNOWN 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER (DESCRIBE IN ITEM D, BELOW) D. IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF // HAZARDOUS SUBSTANCE STORED & GA S. # IV,4 C.A.S. #: xlll. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, & D A. TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER 99 OTHER ❑ 1 STEEL/IRON ❑ 2 STAINLESS STEEL 3 FIBERGLASS F-]4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE 7 ALUMINUM E]8 100% METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER A F-11 RUBBER LINED E]2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING ❑ 6 UNLINED 6 CONCRETE D5 •UNKNOWN U ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 01 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND. U IF UNDERGROUND. BOTH IF APPLICABLE m i A. SYSTEM TYPE A U 1 SUCTION Afi, PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A 6)95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/ FRP A U 8 100% METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL An 95 UNKNOWN A U 99 OTHER LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY, OR S FOR SECONDARY, A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. PS 1 VISUAL CHECK 0 S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P� 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN Pn 99 OTHER . II III VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED (MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK F„ILLED WITH ry SUBSTANCE REMAINING IN INERT MATERIAL? [:]YES ❑ NO /{/ GALLONS 1010 /I i THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME (PRINTED & SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY # JURISDICTION # AGENCY # FACILITY ID # TANK ID # 1010 /I i D D .3 CURRENT LOCAL AGENCY FACILITY ID # APPROVED BY NAME PHONE #WITH AREA CODE e PERMIT NUMBER PE(RMIT//A--PPRO�ViA�L/ AT PERMIT EXPIRATION DATE / 1Q O V CHECK # PERMIT AMOUNT S IRCHARGLfAMTf FEE CODE RECEIPT # BY: FORM B (3-7-88) THIS FORM MUST BE ACCOMPANIHM A FACILITY/SITE APPLICATION, FORM 'A', UNLESS A=ARENT FORM `A' HAS BEEN FILED DATA PROCESSING COPY 10 S