COMPLIANCE INFO_1998-2009 - Laserfiche WebLink

Home Browse Search

• � P�SOUFC f'S C STATE OF CALIFORNIA .P r STATE WATER RESOURCES CONTROL BOARD s I UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B W �' - C1l IROR MIR 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: S �l�a ..�� , _'OaA4 L &,0./ I. TANK DESCRIPTION COMPLETE ALL ITEMS - SPECIFY IF UNKNOWN A OWNER'S TANK I. D. # B. MANUFACTURED BY: C ❑ to REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY1 C. DATE INSTALLED (MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: ©O© Gt Q-` II. TANK CONTENTS IF A-1 IS MARKED, COMPLETE ITEM C. A_ ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C ❑ to REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY1 PRODUCT 1b PREMIUM UNLEADED ❑ 4 GASAHOL E::]7 METHANOL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER ❑ is MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOM D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. #: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A, B, AND C, AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF Ei 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL` 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑` 7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) O 9 BRONZE O 10 GALVANIZED STEEL a 95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 6 UNLINED EJ�� 95 UNKNOWN .�^ 99 OTHER 0 � / F✓y l– COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— TESTING '' MONITORING D. EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION E:]91 NONE 9 ❑ 95 UNKNOWN 99 OTHER If E. SPILL AND OVERFILL CtC, SPILL CONTAINMENT INSTALLED (YEAR) DROP TUBE YES NO HIKER OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) TE YES NO DISPENSER CONTAINMENT Y S NO IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A Cp 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 W1 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 a%99 OTHER O r G! D. LEAK DETECTION[D ,,'MECHANICAL LINE LEAK ❑ 2 UNE TIGHTNESS CONTINUOUS INTERSTITIAL 4 ELECTRONIC LINE ❑ -LEAK AUTOMATIC PUMP ❑ 99 OTHER DETECTOR TESTING '' MONITORING DETECTOR SHUTDOWN V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL ANNUAL RECONCILIATION NTORY ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATGAUGNGIC TANK ❑ 5 MONTORINGGROUND WATER ❑ 6 TESTINGTANK Ea" ' 7 CONTINUOUS MONITORING INTERSTITIAL ❑ 8 SIR ❑ 9 WEETANK GAUGINGAL ❑ 10 TE TINGY TANK E]95 UNKNOWN ❑ 99 OTHER VI. TANK CLOSURE INFORMATION (PERMANENT CLOSURE IN-PLACE) 1. ESTIMATED DATE LAST USED (MO/DAYNR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES ❑NO ❑ 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 b SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION - FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THFORGROUND STORAGE TANK REGULATIONS FORM B (6.95) COUNTY # JURISDICTION # FACILITY # TANK # _.--- STATE LD:# m F PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION - FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THFORGROUND STORAGE TANK REGULATIONS FORM B (6.95)