COMPLIANCE INFO_1991-1994 - Laserfiche WebLink

Home Browse Search

A. OWNER'S TANK I. D. # / vQ B. MANUFACTURED BY: Ou' C. DATE INSTALLED (MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: �? II. TANK CONTENTS IFA -1 IS MARKED- COMPL49TP ITEM C. 1 MOTOR VEHICLE FUEL F --]UNLEADED A. 4 OIL STATE OF CALIFORNIA SOURCES STATE WATER RESOURCES CONTROL BOARD 3 UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B ❑ 1 PRODUCT o ❑ 1bUPREMIUM ❑ 4 AHOL ❑ 7 METHANOL COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM, ❑ 95 UNKNOWN MARK ONLY 0 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL $ED ON SITE ONE ITEM F-]2 INTERIM PERMIT F74 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED D. IF (A.1) IS NOT MARKED, ENTER NAME L) DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 590 Vle-771A ❑ 95 UNKNOWN I. TANK DESCRIPTION COMPLETE ALL ITEMS -- SPECIFY IF UNKNOWN A. OWNER'S TANK I. D. # / vQ B. MANUFACTURED BY: Ou' C. DATE INSTALLED (MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: �? II. TANK CONTENTS IFA -1 IS MARKED- COMPL49TP ITEM C. 1 MOTOR VEHICLE FUEL F --]UNLEADED A. 4 OIL B. C ❑ 1a REGULAR ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT F--]1 BARE STEEL ❑ 1bUPREMIUM ❑ 4 AHOL ❑ 7 METHANOL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN I- 2 WASTE ❑ 6 POLYVINYL CHLORIDE NLEADED ❑ 2 LEADED U FUEL ❑ 5 JFUEL § OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED Q� ❑ 95 UNKNOWN C. A. S. #: III. TANK CONSTRUCWN MARK ONE 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 (VAULTEDTANK) ❑ 99 OTHER B. TANK F--]1 BARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 1009/6 METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER UBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR Iff 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES _ NO D. CORROSION 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 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 IF ABOVE GROUND OR U IF UNDERGROUND. BOTH IFAPPLICARLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE GRAVITY A U 99 OTHER B. CONSTRUCTION A(jq SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND CORROSION PROTECTION A U 1 BARE STEEL A U 5 ALUMINUM A U 9 GALVANIZED STEEL A U A U A U 2 STAINLESS STEEL A U 6 CONCRETE A U 10 CATHODIC PROTECTION 3 POLYVINYL CHLORIDE (PVC) A 4 FIBERGLASS PIPE 7 STEEL W/COATING A 8 100% METHANOL COMPATIBLE W/FRP A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 I I 99 OTHER MONITORING I. TANK AK DETECTION 1 VISUAL CHECK ❑r7INTERSTITIAL VENTORY RECONCILIATION F-]3 VADOZE MONITORING F-14 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING E:]6 TANK TESTING 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 0 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 APPLICANTS 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.# 1"W -E PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE /7 W5 - FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. 0 0