COMPLIANCE INFO_2001-2005 - Laserfiche WebLink

Home Browse Search

0 L7 o0,Ii a�gu�oz. STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARDJiba UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM.0 31b MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSPLQN SITE ONE ITEM F-12 INTERIM PERMIT F-14 AMENDED PERMIT E:]6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED r/ h DBA OR FACILITY NAME WHERE TANK IS INSTALLED: (,,, — ,, _ 4/1� I'll, _ ,)y_ r\_ 1 — I 1. TANK DESCRIPTION COMPLETE ALL ITEMS - SPECIFY IF UNKNOWN A. OWNER'S TANK I. D. # B. MANUFACTURED BY: C. DATE INSTALLED (MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: ILTANKCONTENTS IFA -1 IS MARKED. COMPLETE ITEM C. A 71 ytOTOR VEHICLE FUEL ❑ 4 OIL B. ❑ 95 UNKNOWN C. ❑ 1a REGULAR GADED 3 DIESEL E:]6 AVIATION GAS 4 GASAHOL 2/PETROLEUM ❑ 80 EMPTY ❑ 99 OTHER 1 PRODUCT ❑ lbPREMIUM UNLEADED ❑ 7 METHANOL ❑ 5 JET FUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN B. TANK MATERIAL ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED (PrimaryTank) ❑ 9 BRONZE C. A. S. # III. TANK CONSTRUCTION- MARK ONE ITEM ONLY IN BOXES A, B, AND C, AND ALLTHAT APPLIES IN BOX D AND E A. TYPE OF 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER 1 SINGLE WALL ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE❑NUM A U A U A U ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95UNKNOWN ❑ 99 OTHER INIEHSHTIAL MONITRING ❑ 1 RUBBER LINED F-]2 ALKYD LINING F--]3 EPDXY LINING F-]4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING F]6 UNLINED D �5 UNKNOWN ❑ 99 OTHER LINING 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 NONEUNKNOWN ❑ 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 A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A 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 STEEL W/ COATING A U AO95 UNKNOWN A U 4 FIBERGLASS PIPE 8 100% METHANOL COMPATIBLE W/FRP 99 OTHER D. LEAK DETECTION [::] 1 AUTOMATIC LINE LEAK DETECTOR 0 2 LINE TIGHTNESS TESTING INIEHSHTIAL MONITRING ❑ 99 OTHER V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING a 5 GROUND WATER MONITORING ❑ 6 TANK TESTING a 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 ❑ 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 THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. FORM B (12-91) FILE THIS FORM WITH OCAL AGENCY IMPLEMENTING THE UNDERGROUND STWE TANK REGULATIONS FOR00346-R6 LAPPLICANTS NAMEI (PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE I.D.# COUNTY # JURISDICTION # _ g O FACILITY # TANK # ility` PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE ��l THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. FORM B (12-91) FILE THIS FORM WITH OCAL AGENCY IMPLEMENTING THE UNDERGROUND STWE TANK REGULATIONS FOR00346-R6