COMPLIANCE INFO_1995-1999 - Laserfiche WebLink

Home Browse Search

yr ov 0-0 r " STATE OF CALIFORNIA , STATE WATER RESOURCES CONTROL BOARD "3 1 N: UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B 'h '.. C1l ROI.N+►. COMPLETE A SEPARATE FORM FOR CH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY" LOSED STE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK RE DBA OR FACILITY NAME WHERE TANK IS INSTALLED: b 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A- OWNER'S TANK 1.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAYNEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS 1F A-1 IS MARKED,COMPLETE ITEM C. k ❑ 1 MOTOR VEHICLE FUEL '4 OIL B. C. ❑ 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION'G- ps ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL . ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 1c MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 WASTE ❑ 2 LEADED ❑ 99 0TH (DESCRIBE IN ITEM D. D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.o: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX D AND E 1 DOUBLE WALL 8 SINGLE WALL WITH EXTERIOR LINER 5 INTERNAL BLADDER SYSTEM 95.W90�M ; A. TYPE OF Fi ❑ ❑ ❑ SYSTEM 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT 99 OTHER 5 B. TANK F-1 1 BARE STEEL ❑ 2 STAINLESS STEEL E:T 3 FIBERGLASS. ❑ ;4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL -15 CONCRETE 6 POLYVINYL CHLORIDE �_,_T,ALUMINUM 0 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL I '05 UNKNOWN ❑ 99 OTHER 1 RUBBER LINED 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING C.INTERIOR ❑ � ❑ ❑ LINING OR ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO_ k D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER i E.SPILL AND OVERFILL etSPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) + c. DROP TUBE YES NO STRIKER PLATE YES NO DISPENSER CONTAINMENT YES NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U SUCTION A U 2 PRESSURE A`-U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION ,A 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 NOWN A U 99 OTHER f C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A W 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 D. LEAK DETECTION 1 MECHANIO4L UNE LEAK 2 LINE T1GNrNESS 3 CONTINUOUS INTERSTITIAL 4 ELECTRONIC UNE 5 AUTOMATIC PUMP q DETECTOR TESTING ❑ MOHTORING ❑ LEAK DETECTOR ❑ SHUTDOWN ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 MANUAL NUAL RECONCILIATION ❑ 3 VAOZEMONIITORING ❑ 4 GAUGING AUTOMATIC TANK [75 MONITORINGGROUND WATER 6 TESTINGTANK ❑ 7 MONITORING INTERSTITIAL ❑ 8 SIR ❑ 9 WEEK LY MANUAL E] 10 MONTHLY TANK E:] 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH Y "a NO❑ SUBSTANCE REMAINING -GALLONS INERT MATERIAL 1 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME ! DA '(PRINTED= StGNATUQEI LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# STATE LD:# m PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOUF n PLIED BY A PERMIT APPU '--,o•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED.. aT BE COMPLETED FDA INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PL NG LE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTIZI��OUND STORAGE.TANK+iEGULATIONS FORM B (6.95) P