COMPLIANCE INFO_1986-1997 - Laserfiche WebLink

Home Browse Search

ovwces STATE OF CALIFORNIA r Pa'.. STATE WATER RESOURCES CONTROL BOARD 3y UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B •`�I IIOft 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 F__] »1/// 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ;K 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# ✓3U B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) i9 D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. ❑ 1a REGULAR UNLEADED 3 DIESEL 6 AVIATION GAS A �1 MOTOR VEHICLE FUEL F-1 4 OIL B. C. [—]❑ 1b PREMIUM UNLEADED 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM El 80 EMPTY 1 PRODUCT ❑ 1c MIDGRADE UNLEADED ❑ 5 JET FUEL F-1 8 ME ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE El85 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) 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 �2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ;?� 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE 717 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER 1 RUBBER LINED 3 EPDXY LINING 4 PHENOLIC LINING C.INTERIOR ❑ 2 ALKYD LINING ❑ ❑ LINING OR ❑ 5 GLASS LINING ❑ 6 UNLINED �95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 1000/6 METHANOL? YES— NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION [D 5 CATHODIC PROTECTION ❑ 91 NONE �95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL etc. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) + DROP TUBE YES NO STRIKER PLATE YES NO DISPENSER CONTAINMENT YES NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE ACU,>l SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION AU 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 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 U 5 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑1 MECHANICAL LINE LEAK 2 UNE TIGHTNESS ❑3 CONTINUOUS INTERSTITIAL E:]4 ELECTRONIC UNE [:]5 AUTOMATIC PUMP ❑ 99 OTHER DETECTOR TESTING MONITORING LEAK DETECTOR SHUTDOWN V.TANK LEAK DETECTION ❑ 1 VISUAL CHECKMANUAL 2 RECONCILIATION MONITORING ❑ 3 VADOZEMONITORING ❑ 4 AUTOMATGAUGING MONITORING TANK E::] 5 GROUND MONITORINGTER ❑ 8 ANNUALTESTING ❑ 7 MON TORIOU INTERSTITIAL ❑ 8 SIR E] 9 WEEK LY MANUAL ❑10 TESTING Y TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES E-] NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO TH EST OFAY,KNOWLEDGE,IS TRUE AND CORRECT K OWNER'S NAME (P NTED 6 SIGNA U E) -La 4- _ CxJ• LOCAL AGENd USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBER4ELOW COUNTY# JURISDICTION# FACILITY# b TANK# W C' STATE I.D:# D I/ ?O✓� PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FO C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM FORM B (6-95) SHOULD BE ACCOMPANIED BY A PLOT PILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THEJWGROUND STORAGE TANK REGULATIONS A,ItAl w