COMPLIANCE INFO_1992-2002 - Laserfiche WebLink

Home Browse Search

tyouRceq STATE OF CALIFORNIA �P '• STATE WATER RESOURCES CONTROL BOARD w °m I UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B Y �° COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE TANK REMOVED 6 i DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 'G j I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY 1F UNKNOWN A. OWNER'S TANK I.D.# B. MANUFACTURED BY: ` C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: ('01000 11.TANK C NTS IFA-1 IS MARKED,COMPLETE IT C. j REGULAR E�j A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ taUNLEADED 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 1b PREMIUM ❑ 4 GASAHOL ❑ 7 METHANOL UNLEADED ❑ 5 JET FUEL ❑ 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.#: I III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX D AND E F—] 1 .DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ A. TYPE OF 95 UNKNOWN I ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER SYSTEM ��2 SINGLE WA ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK j MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING F-1 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING 6 UNLINED F—] 95 UNKNOWN ❑ 99 OTHER LINING i, IS LINING MATERIAL COMPATIBLE TH 100% METHANOL? YES_ NO D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ COATING F--] 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(Y R) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) Nit IV.PIPING INFORMATION CIRCLE A IFABOVEGROUND6R U IF UNDERGROUND,BOTH IF APPLICABLE I A. SYSTEM TYPE A U 1 SUCTION A U 2 PRE URE A U 3 GRAVITY A U 99 OTHER r B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBL 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 STAINLES 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 W/COATING A U S 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER 3 INTERSTITIAL D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ MONfTORING ❑ 99 OTHER I V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITQRING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING I. ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE b ❑ 95 UNKNOWN ❑ 99 OTHER i I VI.TANK INF RM ION 1.?T0rtTtDD 7FAAST UW( /DAY/Y2.ESTIMATED QUANTITY OF ( � 3.WAS TANK FILLED Q WITH YES NO. a d SUBSTANCE REMAINING t�,,�' GALLONS INERT MATERIAL? ❑ - T LETED 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 Keo J 1 Q I � COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# 1401 llul PERMIT NUMBER PERM IT APPROVED BY/DATE PERMIT EXPIRATION DATE r THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (12-91) "" FOR0034B-R6 ' ..11