COMPLIANCE INFO_1986-1997 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA ...... STATE WATER RESOURCES CONTROL BOARD 0 UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY Q I NEW PERMIT a 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM F__l 2 INTERIM PERMIT F-] 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED. C k e U t0 r, 9(,01 -21 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN X OWNER'S TANK I.D.# _3 B. MANUFACTURED BY: C. DATE INSTALLED(MC/DAYNEAR) D. TANK CAPACITY IN GALLONS: zo60 0 11.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A. X 1 MOTOR VEHICLE FUEL F-1 4 OIL B. C. to REGULAR UNLEADED ❑ 3 DIESEL D 6 AVIATION GAS F-] lb PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ED 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT 0 1C MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 [] 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE E::] 2 LEADED [-] 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S. 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 X I DOUBLE WALL F__j 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM E:] 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK 0 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 COMPATIBLEW/FRP (Primary Tank) ❑ 9 BRONZE E::] 10 GALVANIZED STEEL ❑ 95 UNKNOWN E] 99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING 0 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING cs 6 UNLINED El 95 UNKNOWN E] 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES® NO— D.EXTERIOR F-] 1 POLYETHYLENE WRAP 2 COATING F-1 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION [:1 5 CATHODIC PROTECTION [_1 91 NONE E:l 95 UNKNOWN ❑ 99 OTHER ENTI E.SPILL AND OV ONTAINM STALLED(YEAR) OVERFIILLPREVENTION EQUIPMENT INSTALLED(YEAR) SPILL C Y --tS-T�IKER PLATE YES OVERFILL,etC- DROP TUBE ES NO — NO DISPENSER CONTAINMENT YES— N IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A@ 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A 0 1 SINGLE WALL A U 2 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)Ao 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLEW/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER 1 MECHANICAL LINE LEAK 2Q 2 LINE TIGHTNESS F-13 CONTINUOUS INTERSTITIAL 4 ELECTRONIC LILEAK DETECTOR SHUTDOWN E]NE D. LEAK DETECTION C4 DETECTOR TESTING MONITORING Ll 5 AUTOMATIC PUMP 99 OTHER V.TANK LEAK DETECTION I VISUAL CHECK 2 93 MANUAL INVENTORY F__j 3 VADOZE ❑ 4 AUTOMATIC TANK E:j 5 GROUND WATER F__j 6 ANNUALTANK RECONCILIATION MONITORING GAUGING MONITORING TESTING 7 MONITORING99 OTHER ED CONTINUOUS INTERSTITIAL E] 8 SIR E] 9 WEEKLY MANUAL ❑10 MONTHLY TANK E:l 95 UNKNOWN TANK GAUGING TESTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) i.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES E I 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 I D (PRINTED&SIGNATURE) 1�11FI6 -LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FO NUMBERS BELOW STATE I.D.4 COUNTY# JURISDICTION# FACILITY# TANK#TTI FT= 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 PLAN. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (6-95)