COMPLIANCE INFO_1986-1996 - Laserfiche WebLink

Home Browse Search

t ",gyp ey STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B COMPLETE A SEPARATE FORM FO!,LXH TANK SYSTEM MARK•ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANE cud. ON SIT ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ❑ 8 TAN EIf V DBA OR FACILITY NAME WHERE TANK IS INSTALLED: A2.(-o I;'F4(_ tl®. OSS$ f 1. TANK DESCRIPTION COMPLETE ALL ITEMS-SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# 5 1 S. MANUFACTURED BY: U N44b-1 O w IJ C. DATE INSTALLED(MO/DAY/YEAR) 05 0. TANK CAPACITY IN GALLONS: SSO II.TANK CONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. n A. ❑ 1 MOTOR VEHICLE FUEL �4 OIL 8. C ❑ to REGULAR 3 DIESEL 6 AVIATION GAS f72 PETROLEUM F780 EMPTY r71 PRODUCT F7tb PREMIUM u a GASOHOL (❑ 7 METHANOL UNLEADED5 JETFUEL C:] 3 CHEMICALPRODUCT C:] 95 UNKNOWN -2 WASTE ❑ 2 LEADEDR-9, OTHER (DESCRIBE IN ITEM 0. BELOW) D: IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED VSEL P"o-rog- bIC... C.A.S.a: BOOlQ�1 . III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.S.AND C.AND ALL THAT APPLIES IN BOX O AND E A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM [2-2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK Cel BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ® 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) E:l 9 BRONZE (� 10 GALVANIZED STEEL C:] 95 UNKNOWN ❑ 99 OTHER F71 RUBBER LINED ❑ 2 ALKYD LINING F73 EPDXY LINING ❑ 4 PHENOLC LINING C.INTERIOR t_J 5 GLASS LINING 7A f S UNLINED ❑ 95 UNKNOWN ® 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODC PROTECTION ❑ 91 NONE 215 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EOUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY Ao 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN AQ 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U a FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 8 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U�99 OTHER h10•.lt 0. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 UNE TUHTNESS TESTING ❑ "Mill MONITOl 141 ❑✓r99 OTHER !4 V.TANK LEAK DETECTION �i VISUAL CHECK ® 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING❑ 5 GROUND WATER MONITORING �❑C�6 TANK TESTING ® 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER Vi.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES NO SUBSTANCE REMAINING GALLONS IINERT MATERIAL? u THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE iPRINTEDa SIGNATUR w I Z ZI,-q� LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPO D OFTHE FOUR NUMBERS BELOW COUNTY x JURISDICTION tt FACILITY st TANK x STATE I.D.#� , la[! l��' 12-1`144 �i O 15, V I� PERMIT NUMBER i PERMIT APPROVED SY/OATE I PERMIT EXPIRATION DATE FORM a p-s1) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOR069a"