COMPLIANCE INFO_1986-1997 - Laserfiche WebLink

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STATE OF CALIFORNIA "" STATE WATER RESOURCEd CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM BCW COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. ARK ONLY Q 1 NEW PERMIT F7 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION - 7 PERMANENTLY CLOSED,. ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT SURE ❑ 8 TANK REMOVED 2+i DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK 1.D.X B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: ' ILTANKCONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. A. ❑ 1 MOTOR VEHICLE FUEL 4 OILg, C 1a REGULAR ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ UNLEADED ❑ 4 GASAHOL 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT ❑ 1bPREMIIUMUNLEADED ❑ 5 JET FUEL ❑ 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 NAME OF SUBSTANCE STORED C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALLTHAT APPLIES IN BOX D AND E A. TYPE OF 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER a 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 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 (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING F—] 4 PHENOLIC LINING C.INTERIOR rkr 5 GLASS LINING O 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING r— IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 3;�r4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION a 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) !D OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVE G OUNDOR U IFUND GROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION -URE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1SINGLE WAL DOUBLE WALL A U 3 LINED TRENCH A U 95 ^ NOWN A U 99 OTHER C. MATERIAL AND A U 1 BAR A STEEL A U 3 POLYVINYL CHLORIDE(PVC)A 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 PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION . 1 AUTOMATIC LINE LEAK DETECTOR2 LINE TIGHTNESS TESTING 3 A [:] ❑ MONITORING ❑ 99 OTHER V.TANK LEAK DETECTION FE 1 VISUAL CHECK 2 INVENTORY RECONCILIATION F-13 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING [-] 5 GROUND WATER MONITORING 6 TANK TESTING INTERSTITIAL MONITORING ❑ 91 NONE F-] 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 SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 YES NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED 8 SIGNATURE) � L, s LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OFTA FOUR NUMBERS BELOW STATE LD.# COUNTY# JURISDICTION# FACILITY# TANK#. PERMIT NUMBER PERMIT APPROVED BY/DATE RtRMIT EXPIRATION DATE f 'l THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS C Cl FORM B (12-91)