COMPLIANCE INFO_2001-2005 - Laserfiche WebLink

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�••18to� O a. ep Rces STATE OF CALIFORNIA `•'�, STATE WATER RESOURCES CONTROL BOARDAba UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM Bio ,�, • C�[IFpP N.r COMPLETE A SEPARATE FORM FOR !2 TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS''� SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED ( / / J t DBA OR FACILITY NAME WHERE TANK IS INSTALLED: S k p I. TANK DESCRIPTION COMPLETE ALL ITEMS -- SPECIFY IF UNKNOWN �7 A. OWNER'S TANK 1. D. # B. B. MANUFACTURED BY: C. DATE INSTALLED (MO/DAY/YEAR) k D. TANK CAPACITY IN GALLONS: IL TANKCONTFNTS IFA-1I.SMARKFD COMPLETE ITEM C. y % A ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. to REGULAR 3 DIESEL ❑ 6 AVIATION GAS C• ❑ ❑ 95 UNKNOWN SYSTEM UNLEADED 4 GASAHOL PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ lb PREMIUM ❑ 7 METHANOL UNLEADED 0 JET L ❑ 3 CHEMICALPRODUCT E:]95 UNKNOWN 2 WASTE 0 ❑ 2 LEADED 99OTHER(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. 8. AND C_ AND ALL THAT APPI IFS IN ROX D AND F A. TYPE OF Eol'i DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER A U ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑�INUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER A U ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING XY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING E-15 GLASS LINING F--]6 UNLINED 95 UNKNOWN ❑ 99 OTHER A U IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— A U D. CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑3 YL 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 IFABOVEGFIOUNDOR U IF UNDERGROUND. BOTH IFAPPLICABLE A. SYSTEM TYPE A n 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY 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 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&)95 UNKNOW A U 99 OTHER D. LEAK DETECTION [:]1 AUTOMATIC LINE LEAK DETECTOR 3 ❑ 2 LINE TIGHTNESS TESTING 10 INfERSTITIAL ❑ 99 OTHER MONrroRING V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI. TANK CLOSURE INFORMATION 1. ESTIMATED DATE LAST USED (MO/DAY/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES 0 NO ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, 1S 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 # 9 (pyo TANK # STATE I.D.# ®—� g n� 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. FILE THIS FORM WITH TfpCAL AGENCY IMPLEMENTING THE UNDERGROUND STWE TANK REGULATIONS FORM B (12-91) FQROQ348-4