COMPLIANCE INFO_1986-2004 - Laserfiche WebLink

Home Browse Search

t STATE OF CALIFORNIA P�SouRc,: wP * Or STATE WATER RESOURCES CONTROL BOARD 3 + g UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B "� me •CSI IIOR N' COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED=0 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: j"(� c_ ` 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK 1.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) Lam✓ " `-� D. TANK CAPACITY IN GALLONS: 11.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. V�✓v p,_ MOTOR VEHICLE FUEL ❑ 4 OIL B, C ❑ 1a REGULAR UNLEADED E:] 3 DIESEL ❑ 6 AVIATION GAS ��/' E:] lb PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ 80 EMPTY `PRODUCT ❑ is MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOM D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM x 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ,/ ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL V95 GLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL � 5 CONCRETE ❑ 6 POLYVINYL CHLORIDEINUM ❑ B 100% METHANOL COMPATIBLEW/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEELNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 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% MET NOL? YES_ NO-- D.EXTERIOR F1 1 POLYETHYLENE WRAP ❑ 2 7NE G 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION El CATHODIC PROTECTION �91 ❑ 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL etc. SPILL CONTAINMENT INSTALL Y R) OVERFILL PREVENTI N EQUIPMENT INSTALLED(YEAR) + DO DROP TUBE YES N STRIKER PLATE YES NO DISPENSER CONTAINMENT YES NO IV.PIPING INFORMATION CIRCLE A IF A VE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEE A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINU A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVA ED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 0 1 MECHANI LINE LEAK �2 LINE TIGHTNESS [:]3 CONTINUOUS INTERSTITIAL 0 4 ELECTRONIC LINE �5 AUTOMATIC PUMP ❑ 99 OTHER DETECTO TESTING MONITORING LEAK DETECTOR SHUTDOWN V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 MANUAL RECONCILIATION NORY r-13 VADOZE MONITORING ❑ 4 AUTOMATGAUGING MONITORING TANK ❑5 GROUND MONITORINGTER 6 ANNUALTESTINGTANK ❑ 7 CONMON INUOU INTERS IAL El SIR ❑ 9 WENEKLY K GA MANUAL ❑10 MO TIN LY TANK 95 UNKNOWN 99 OTHER ORINVI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED 0/ /YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO a SUBSTANCE REMAINING X' 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 OWNER'S NAME DATE (PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.Dl m E PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE /r THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLVLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE WGROUND STORAGE TANK REGULATIONS FORM B (6-95) ��;�� `� ��