COMPLIANCE INFO_1993-1998 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1711 NEW PERMIT ❑ 3 RENEWAL PERMIT D. TANK CAPACITY IN GALLONS: I /fit 0 0 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT F-1 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 7H, &6 1 c, c' H z lb -5 - I. TANK DESCRIPTION COMPLETE ALL ITEMS -- SPECIFY IF UNKNOWN A. OWNER'S TANK I. D. # B. MANUFACTURED BY:(Gs R XCC C. DATE INSTALLED (MO/DAY/YEAR) 'J D. TANK CAPACITY IN GALLONS: I /fit 0 0 ILTANKCONTENTS IFA-11SMARKED.COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL 4 OIL ❑ B. ❑ la REGULAR C. ❑ ❑ UNLEADED3 DIESEL 6 AVIATION GAS F-12 PETROLEUM ❑' 80 EMPTY E711PRODUCT [3'" b PREMIUM ❑ 4 GASAHOL ❑ T METHANOL UNLEADED ❑ JETFUEL 3 CHEMICAL.PRODUCT 95 UNKNOWN ❑ ❑ 2 WASTE 2 LEADED ❑ ( ❑ 99 DESCRIBE IN ITEM D. BELOW) D. IF (A.1) IS NOT MAR D, ENTER NAME OF SUBSTANCE STORED C. A. S. i Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A 8. -ANDD. AND ALL THAT APPLIES IN ROX O AND F A. TYPE OF ❑f 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑' 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER 7 STEEL W/COATING A U ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING [:7�'6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER [7]1ry IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND. BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A 0 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 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 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 D. LEAK DETECTION [7]1ry AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 ❑ 99 OTHER MONITORINGINTERSTITIAL V. TANK LEAK DETECTION 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING 6 TANK TESTING. [X7 INTEASTITIALMONIT6Rtma 0,.01: NONE Lj 95 UNKNOWN ❑ 99 OTHER A TANK CLOSURE INFORMATION [7aTIMATED DATE LAST USED (MO/DAY/YR) 2: ESTIMATED QUANTITY OF 3 WAS TANK FILLED WITH YES ❑ NO ❑ 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 DATE (PRINTED 8 SIGNATURE) �� ) (-, f��iT��1 ; AGN . � _ , I• �(- 3 - LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER 1S COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # TANK # STATE LD.# ❑ I I , - PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION - FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. �