INSTALL_1988 - Laserfiche WebLink

Home Browse Search

FORM 'B': UNDERGROND STORAGE TANK INFORMAN and/or PERMIT APPLICATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT 3,-RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 TANK REMOVED ONEITEM ❑ 21NTERIM PERMIT MENOED PERMIT ❑6TEMPORARY TANK CLOSURE ❑BPERMANENTLY CLOSED TANK FARM TANK YES NO FACILITY/SITE NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK I.D.M /-OGS B. MANUFACTURED BY: lle'�III C. YEAR INSTALLED 0. TANK CAPACITY IN GALLONS: Q II. TANK C NTENTS IF(A.1),IS MARKED,COMPLETE ITEM B.IF(A.1),IS HOT M KED,COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 2 OTHER PETROLEUM PRODUCT B. 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT F-14 WASTE OIL ❑ 1 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 OTHER HAZARDOUS WASTE ❑ 80 EMPTY ❑ 95 UNKNOWN ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM C.BELOW) C. IF NOT MOTOR VEHICLE FUEL,ENDER NAME OF C.A.S.C HAZARDOUS SUBSTANCE STORED 8 CAS.# III. TANK CONSTRU TION MARK ONE ITEM ONLY IN BOX A,S,C,D A.TYPE OF 5erI DOUBLEWALLFD ❑ 2 SINGLE WALLED ❑3 SINGLE WALLED WITH EXTE+:OR LINER — SYSTEM ❑ 4 SECONDARY CONTAINMENT ❑95 UNKNOWN ❑99 OTHER F-11 STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL CUD W/RBERGLASSPENFORCEO PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑8 I00%METHANOL COMPATIBLE- MATERIAL OMPATIB E FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN 99 OTHER ❑ I RUBBER LINED F-1 2 LAYOUNING F-13 EPDXY LINING ❑4 PHENOJCUNING C.INTERIOR ❑5 GLASS LINING NUNED ❑91 NONE ❑95 UNKNOWN LINING ❑ IS LINING MATERIAL COMPATIBLE WITH 100%NETHANOL? ❑YES ❑ NO ❑W OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑ 2 TARORASPHALT ❑3 VINYL WRAP 4 FIBERGLASSREINfORCEDPLA$IIC PROCTECTION ❑ 5 CATHOOIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U I SUCTION A PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A U I SINGLE WALLED et>2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A®4 FIBERGLASS PIPE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL Cl—ADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FORPRIMARY,OR S FOR SECONDARY S 1VISUAL CHECK R S 2 INVENTORY RECONCILIATION P S 4VADOSE WELLS P®4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTI# S 7 PRESSURE TESTING P 5 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2.�I�GALLOI ANTITY Of J.WAS TANK FILLED WITH EMAINING INERT MATERIAL? ❑YES ❑ NO THIS FOLAPPLI HAS BEEN COMPLETED UNDER PENALTY OF PERJURY.AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT NT'S NAME(PRINTED 8 SIGNATURE) RW . /ZZO DATE LOCAL AGENCY LIA O LY A O L COUNTY N rJURISDICTION N AGENCY N FACILITY ID N TANK ID# m CURRENT LOCAL AGENCY ID# PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE FEE CODE CHECK# AMOUNT SURCHARGE AMT. RECEIPT N BY: FOPM B O1 88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION,FORM W,UNLESS A CURRENT FORM 'A' HAS BEEN FILED