COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

0 gJUR ES STATE OF CALIFORNIA • �G �° STATE WATER RESOURCES CONTROL BOARD 3 _. UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SIT ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 2 WASTE 6 TEMPORARY TANK CLOSURE �vwi/8 TANK REMOVED 0 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: C7 etQ ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC L j IS0 Q -q I. TANK DESCRIPTION rnMPI FTF Al I ITFMS -- SPFCIFV IF I INKNnWN ❑ 8 1009% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE A. OWNER'S TANK I.D.# d2 B. MANUFACTURED BY: G C. DATE INSTALLED(MO/DAY/YEAR) V.1 If-- D. TANK CAPACITY IN GALLONS: �OQ II_ TANK CONTENTS IFA-1I.CMARI(FnrnMPICTGITCMr A. 1 MOTOR VEHICLE FUEL F -]1a 4 OIL B. REGULAR 3 DIESEL C• ❑ UNLEADED 1:16 AVIATION GAS F-]2 PETROLEUM F-180 EMPTY PRODUCT lbPREMIUM❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 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 MAGI( nNG ITFKA nNl V IN PnYce A P AAIn r Akin Al 1 TUAT AOD1 — --- A— A. TYPE OF 11 DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM �❑ 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK F-]1 BARE STEEL F-]2 STAINLESS STEEL F-13 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE 7 ALUMINUM ❑ 8 1009% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER F-]1 RUBBER LINED F72 ALKYD LINING F-]3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING F-]5 GLASS LINING E]6 UNLINED 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 CATHODIC PROTECTION ❑ 91 NONE UNKNOWN ❑ 99 OTHER E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) IV. PIPING INFORMATION rIRrtF A IFAnnvFQRnIINnnG 11 IF IINnFG(]GnI IAIn DnTU IC ADDI IrA01C A. SYSTEM TYPE A U 1 SUCTION A(Sh PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND CORROSION PROTECTION A U A U A U 1 BARE STEEL 5 ALUMINUM 9 GALVANIZED STEEL A U A U A U 2 STAINLESS STEEL A U 6 CONCRETE A U 10 CATHODIC PROTECTION 3 POLYVINYL CHLORIDE (PVC) A U 7 STEE/COATING A U A U 9 UNKNOWN A U 4 FIBERGLASS PIPE 8 1009/6 METHANOL COMPATIBLEW/FRP 99 OTHER D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR2 LINE TIGHTNESS TESTING 3 INTERSTITIAL ❑ ❑ MONITORING ❑ 99 OTHER V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORINC ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI. TANK CLOSURE INFORMATION 1. ESTIMATED DATE LAST USED (MCl/DNR) 2• ESTMATEDSUBISTANCEOREMAI NGP __GALLONS 3. WA INERT MATERIALI?TANK FILLED WTH YES ❑ NO�,� THIS FORM HASBEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS 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.D.# FM 1 Fff o -> lo 7 0 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE /7--13-73 cr/L FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION - FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED.