COMPLIANCE INFO_1995-1999 - Laserfiche WebLink

Home Browse Search

4.1 STATE OF CALIFORNIA °5 STATE WATER RESOURCES CONTROL BOARD' ` UNMRGRQUND 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 CLOS N SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED si DBA OR FACILITY NAME WHERE TANK IS INSTALLED, I. TANK DESCRIPTION COMPLETE ALL ITEMS•- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# r B. MANUFACTURED BY: { I C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: rfi II.TANK CONTENTS IFA-1 1S MARKED,COMPLETE ITEM C. A• �ft MOTOR VEHICLE FUEL ❑ 4 OIL e. C, ❑ la REGULAR 3 DIESEL ❑ 6 AVIATION GAS 4 I 2 PETROLEUM F-180 EMPTY �1 PRODUCT. ❑ 1b PREMIUM ❑ 4 GASAHOL 7 METHANOL I ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTEUNLEADED ❑ 5 JET FUEL 2 LEADED ❑ 99 OTHER (DESCRIBE IN.IT BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.X III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,ANOC,AND ALL THAT 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 3 r B. TANK El1 BARE STEEL F__] 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD.Wl'FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER N ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING =' C.INTERIOR LINING ❑ 5 GLASS LINING �-6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO D.CORROSION ❑ 1 POLYETHYLENE WRAP F—] 2 COATING F—] 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑€6 UNKNOWN. ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IFUNDERGROUND,BOTH IFAPPLICAQI$ A. SYSTEM TYPE A.0 1 SUCTION AU02 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U2 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,STEL 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 U 95 UNKNOWN A U 99 OTHER 3 INT AL b. LfAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR 0 2 LINE TIGHTNE `tESTING ❑ MONITORING ❑ 99 OTHER V.TANK LEAK DETECTION ❑ i VISUAL CHECK F—] 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING 0 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING F—] 7 INTERSTITIAL MONITORING ❑ 91 NONE -06 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION FESTIMATED DATE LAST USED(MO/DAY VR) 2.ESTIMATED QUANTITY Of° 3.WAS TANK FILLED WITH YES NO ' t 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 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.# 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 THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (12-91) • FOR00348-R6