COMPLIANCE INFO_1992-2001 - Laserfiche WebLink

Home Browse Search

lty0u.c�s STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B .510.1 i I . .0 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT F-] 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON TE ONE ITEM F-] 2 INTERIM PERMIT F__j 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED I I DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. 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 GALLONgL. 11.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A. F-]1 MOTOR VEHICLE FUEL 4 OIL B. C. la REGULAR UNLEADED F-]3 DIESEL 6 AVIATION GAS 12 PETROLEUM E] 80 EMPTY F'qgr 1 PRODUCT lb PREMIUM UNLEADED ❑ 4 GASAHOL E 7 METHANOL El 1C MIDGRADE UNLEADED ❑ 5 JET FUEL F-1 8 M85 0 3 CHEMICAL PRODUCT El 95 UNKNOWN 2 WASTE ❑ 2 LEADED Ej 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.III: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF ]Na-1 DOUBLE WALL F__j 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM r_-] 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL E-1 4 SINGLE WALL IN A VAULT F-] 99 OTHER B. TANK ❑ I BARE STEEL F__] 2 STAINLESS STEEL l-3 FIBERGLASS 0 4 STEEL CLAD W1 FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLEW/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL E] 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED 2 ALKYD LINING F-] 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR F-] 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES "Y NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP 0 2 COATING Ej 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION E] 91 NONE 44 ❑95 UNKNOWN E::] 99 OTHER SPILL CONTAINMENT INSTALLED(YEAR) - Fd OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) __^4 E.SPILL AND OVERFILL,etc. 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 1 SUCTION �&IPRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL 6-Af 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)k04 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELWICOATING A U 8 1001/6 METHANOL COMPATIBLEW/FFIP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION W MECHMCAL LINE 2 LINE TIGHTNESS or CONTINUOUS INTERSTITIAL M 4 ELECTRONIC LINE AUTOMATIC PUMP E:] 99 OTHER DETECTOR TESTING ..MOMTORING LEAK DETECTOR SHUTDOWN V.TANK LEAK DETECTION El 1 VISUAL CHECK ❑ 2 MANUAL INVENTORY ❑ 3 VADOZE ❑ 4 AUTOMATIC TANK F-15 GROUNDWATER ❑ 6 ANNUAL TANK RECONCILIATION MONITORING GAUGING MONITORING TESTING 7 CON ITTINUOUS INTERSTITIAL E] 8 SIR ❑ 9 WEEK EKLY MANUAL ❑10 MOTESTINGNTHLY TANK 0 95 UNKNOWN E:] 99 OTHER MORING GAUGING VLTANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES NOE:] L ESTIMATED DATE LAST USED(MO/DAY/YR) NF-1—1 SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT _TANK OWNER'S NAME DATE (PRINTED&SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.40 KEE7 I?" �_ �?I I I PERMIT NUMBER PERMIT APPROVED BY/DATE ER T EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLIOCO FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED.[fC MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PI IETHIS FORM WITH THE LOCAL AGENCY IMPLEMENTING TH RGROUND STORAGE TANK REGULATIONS FORM B (6-95) t6 it