COMPLIANCE INFO_1987-1992 - Laserfiche WebLink

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• • y0U"GES STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B FQ� COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: —7 /^ I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: II,TANKC NTS IFA-1 IS MARKED,COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OILB. C. ❑ 1aREGULARUNLEADED ❑ 3 DIESEL ❑ 6 AVIATIONGAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 1b PREMIUM ❑ 4 GASAHOL ❑ 7 METHANOL LEADED 5 JET FUEL ❑ F—] 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE � ED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SLCSTANCE STORED C.A.S.#: III. TANK CONSTRUCTION MARK ONE 14 ONLY IN BOXES A.8,AND C,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 - N 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER ❑ B. TANK 1 BARE STEEL E:1 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL F—] °/5 CONCRETE ❑ LYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 AL D LINING F—] 3 EPDXY LINING F—] 4 PHENOLIC LINING LINING C.INTERIOR F—] 5 GLASS LINING ❑ 6 UNLI ED F—] 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% THANOL? YES_ NO D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATIN ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF VERGROUND,BOTH IFAPPLICABLE A. 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 WAL 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 STL 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 PROT CTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE T HTNESS TESTING3 INTERS I IAL ❑ MONITORING ❑99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MO TORING ❑ 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. ST 7ATR DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? HIS FO M HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED b SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# ❑❑ PERMI NU BER9 PERMIT APPROVED BY/DATE PERMITEXPIRATIO ATE �..- z--- FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. // FOROQ:WB•RS ol�