COMPLIANCE INFO_1988-2004 - Laserfiche WebLink

Home Browse Search

s . STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM H COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT � 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY ITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑ i TANK REMOVED D/ DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 1. TANK DESCRIPTION _ COMPLETE ALL ITEMS-SPECIFY IF UNKNOWN A.OWNERS TANK I.O.s t B. MANUFACTURED C. DATE INSTALLED(MO/DAY/YEAR) O. TANK CAPACITY IN GALLONS: O II.TANK CONTENTS IFA•1ISMARKED.COMPLETE ITEM C. A. (l 1 MOTOR VEHICLE FUEL ❑ 4 OIL B, C ❑ I& EADED REGULAR 3 DIESEL F76 AVIATION GAS ❑ 2 PETROLEUM ❑ 60 EMPTY 1 PRODUCT lb PREMIUM 4 GASAHOL 7 METHANOL UNLEADED 5 JET FUEL ❑ ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED El 99 OTHER (DESCRIBE IN ITEM 0. BELOW) D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.s: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOX 0 AND E A. TYPE OF 91 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 90 OTHER ❑ B. TANK 1 BARE STEEL F72 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CIAO W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 100% METHANOL COMPATIBLE W/FRP (PrimmyTink) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER F71 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR LINING ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN 99 OTHER C IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES—';4_ NO D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION C,'EL 91 NONE ❑ 95 UNKNOWN ❑ 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&)2 PRESSURE A U 3 GRAVITY A U 99 OTHER S. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A LU "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 D FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 6 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHOOIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR 2 UNE TIGHTNESS TESTING ❑ MONITORING ❑ g9 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK-5EP-2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING �j6 TANK TESTING r5z. 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) I 2 ESTIMATED OUANT11TY OF 3.WAS TANK FILLED WITH YES NO SUBSTANCE REMAINING GALLONS ❑ INERT MATERIAL? ❑ THIS FORM HAS 8 N C,PMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGF_ IS TRUE AND CORRECT APPLICA S NAME J y7 (PRI iSIGNA7V / // THTj�i / I DATE I I LOCAL AGENCY SE ONLY THE STATE 1.0.NUMBER tS COM OSED OFTHE FOUR NUMBERS BELOW COUNTY# JURISDICTION x FACILITY s ' TANK s DD STATE LD.# ® 13 L212 a --9' 714M O O -171 PERMIT NUMBER PERMIT APPROVED 13YIOATE 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 8 (12.91) � t � P0104Ji111446 4