COMPLIANCE INFO_1987-1992 - Laserfiche WebLink

Home Browse Search

iA. 50URCE5 STATE OF CALIFORNIA Pt s STATE WATER RESOURCES CONTROL BOARD a _ UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B a .` 0 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED 1 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: D. IF (A.1) IS NOT MARKED, ENTER NAM OF SUBSTANCE STORED C. A. S. #: F—]2 STAINLESS STEEL I. TANK DESCRIPTION COMPLETE ALL ITEMS -- SPECIFY IF UNKNOWN A. OWNER'S TANK I. D. # B. MANUFACTURED BY: C. DATE INSTALLED (MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: I, TANK GD TENTS IFA -1 IS MARKED, COMPLETE ITEM C. m A. Fvl1 MOTOR VEHICLE FUEL ❑ 4 OIL B, C 1a REGULAR ❑ 3 DIESEL ❑ 6 AVIATION GAS UNLEADED F—]2 PETROLEUM F-180 EMPTY 1 PRODUCT ❑ q GASAHOL ❑ lb PREMIUM UNLEADED ❑ 5 JET ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAM OF SUBSTANCE STORED C. A. S. #: III. TANK CONSTRUCTION MARIXONE ITEM ONLY IN BOXES A. B. AND C. AND ALL THAT APPLIES IN BOX D AND F 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 B. TANK ❑ 1 BARE STEEL F—]2 STAINLESS STEEL F—]3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 1009/ METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER AUTOMATIC LINE LEAK DETECTOR [:]V LINE TIGHTNESS TESTING ❑ 3 INTERSTITIAL MONITORING ❑ 1 RUBBER LINED 2 ALKYD LINING ❑ 3 EPDXY LINING F—]4 PHENOLIC LINING C. INTERIOR F--]5 GLASS LINING 6 UNLINED El95 UNKNOWN 99 OTHER LINING -..- IS LINING MATERIAL COMPATIBLE WI 100% METHANOL? YES_ NO D. CORROSION ❑ 1 POLYETHYLENE WRAP ❑COATING F--]3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION F-15 CATHODIC PROTECTION [—]91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED ( AR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) IV. PIPING INFORMATION CIRCLE A IF AROVFGROUNAOR U IF I INDFRr.ROIIND RnTU IG APPI InAPIF A. SYSTEM TYPE A U 1 SUCTION A U 2 P SSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DO BLE 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 STAI LESS STEEL A U 6 CON ETE A U 10 CATH DIC PROTECTION 3 POLYVINYL CHLORIDE (PVC) A U 7 STEEL W/COATING A U A U 95 UNKNOWN A U 4 FIBERGLASS PIPE 8 100°/ METHANOL COMPATIBLE W/FRP 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR [:]V LINE TIGHTNESS TESTING ❑ 3 INTERSTITIAL MONITORING ❑ gg OTHER V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VA ZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING E::]7 INTERSTITIAL MONITORING ❑ 91 N E ❑ 95 UNKNOWN ❑ 99 OTHER VI. TANK CLOSURE INFORMATION 1. STIMAT D DATE LAST USED (MO/DAY/YR) 72., ESTIMATED QUANTOF 3. WAS TANK FILLED WITH YES ❑ NO ❑ SUBSTANCE REMAINI G GALLONS INERT MATERIAL? I FORM HAS BEEN COMPLETED UNDER PENALTY OF PERDU Y, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAMEDATE (PRINTED a SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW &j)C,0,S, 7 9 COUNTY # JURISDICTION # FACILITY # TANK # STATE I.D.# I I1/nlj!�l = PERMITN BER PERMIT APPROVEDY/DATE PERMIT EXP ATION ATE FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION - FORM GAJ, UNLESS A CURRENT FORM A HAS //BEEN FILED. �Yk FOR00348•RS