BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA / STATE WATER RESOURCES CONTROL BOARD v UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B 1. IJ41vnMWbnIrIIVPI COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I. D. # or B. MANUFACTURED BY: I J C. DATE INSTALLED (MO/DAYYYEAR) D. TANK CAPACITY IN GALL S: II TAMICCflNITFARC ,�.........��.. ........, �_��.._ _ - A. ❑ 1 MOTOR VEHICLE FUEL 4 OIL B. C• ❑ 1. REGULAR3 DIESEL ❑ 6 AVIATIONGAS ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ P :T BBBDDDDDDBBBB 1b PREMIUM 4 GASAHOL 7 METHANOL O ❑ ❑ 3 CHEMICAL PRODUCT ❑ 96 UNKNOWN 2 WASTE UNLEADED ❑ 5 JET FUEL i BARE STEEL 2 STAINLESS STEEL O 2 LEADED Ej BB OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. # III. TANK CONSTRUCTION M ARK nNF ITPUnNIVINMI .. P nun, nnm n,I,—.— ,u nr.— -- A. TYPE OF ❑ 1 UBLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER - B. TANK i BARE STEEL 2 STAINLESS STEEL ❑ 3 FIBERGLASS O 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM O 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER 4 FIBERGLASS PIPE 8 100% METHANOL COMPATIBLE WFRP 99 OTHER ❑ 1 RUBBER LINEO❑ LINING 3 EPDXY LINING E::]4 PHENOLIC LINING C. INTERIOR LINING F75 GLASS LINING 8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES _ NO— D. CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 ING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODICPROTECTION 1 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) IV. PIPING INFORMATION CIRCLEAIFABOVEGROUNDORUIFUNDERGROUND-BOTHIFAPPIIDAWF A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A 42 3 ORA ITY A U 99 OTHER B. CONSTRUCTION A U 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 A U A U 1 BARE STEEL 5 ALUMINUM 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 U 7 STEEL W/ COATING A U A U 95 UNKNOWN A U 4 FIBERGLASS PIPE 8 100% METHANOL COMPATIBLE WFRP 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR [:]2 LINE TIGHTNESS TESTING = MONROPoNG ❑ 99 OTHER 1. TANK LEAK DETECTI/OV- ❑ i VISUAL CHECK I;� 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL 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 SUBSTANCE REMAINING GALLONS INERT MATERIAL? 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 (PRIM0 a SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # �TANK �# 1 STATE I. D.# 3 7 FT17 o PERMIT NUMBER PERMIT APPROVED BV/DATE PERMIT EXPIRATION DA PERMIT NUMBER —7� FORM 6 (7.91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED N✓ 1.4 b