COMPLIANCE INFO_FILE 10 - Laserfiche WebLink

Home Browse Search

• STATE OF CALIFORNIA • ��f�5 STATE WATER RESOURCES CONTROL BOARD W' o NDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B , „ o• COMPLETE A SEPARATE FORM FOR EAC ANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLYO S ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOV o U DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ce�olzlz ae- L (� S'� 4 I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.A /S _ l / B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) (J G� v D. TANK CAPACITY IN GALLONS: II.TANKC,RWENTS IFA-1 IS MARKED,COMPLETE ITEM C. A r i MOTOR VEHICLE FUEL 4 OIL B. C. E:] 1aUNLEADED DIESEL 6 AVIATION GAS F__] 2 PETROLEUM El80 EMPTY / PRODUCT ❑ Ib PREMIUM 17 4 GASAHOL ❑ 7 METHANOL ❑ UNLEADED JET L 3 CHEMICAL PRODUCT [:j95 UNKNOWN ❑ 2 WASTE 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.i 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 �SI LE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER BARE STEEL F__] 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL 5 CONCRETE 6 POLYVINYL CHLORIDE 7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER ❑ 1 RUBBER LINED 2 ALKYD LINING 3 EPOjPF tiNING 4 PHENOLIC LINING C.INTERIOR F—] 5 GLASS LINING F__] 6 UNLINED UNKNOWN 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 1009 METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VI RAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE5 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 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 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 U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 MOTH f ING ❑ 99 OTHER V. ANK 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 YES Nj SUBSTANCE REMAINING GALLONS INERT MATERIAL^ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLE E, IS TRUE AND CORREC APPLICANTS NAME DATE (PRINTED b SIGNATURE) /1 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# 1 TANK# STATE IBM �� O PERMIT NUMBER �] PERM T PROVED BY/DATE PER IT EXPIRATION DATE xa THIS FORM MUST BE ACCOMPANIED13Y A PERMIT APPLICATION-FORMA,UNLESS A CURRENT HAS I FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS rw ` FORM B (12-91) `�L FOR00346-R6