BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATEOFCAUFORMA STATE WATER RESOURCES CONTROL BOARD ° UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B a COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENT L M ONE REM ❑ 2 INTERIM PERMIT F--] 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK R OV DBA OR FACILITY NAMEWHERE TANK IS INSTALLED:/,2-,,_'5r C—,f5;',j^lA�'iL 9 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MOVDAYIYEAR) D. TANK CAPACITY IN GALLONS: 6-00 ILTANKCONTENTS IFA-1 ISMARKED,COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL 9, C 1e REGULAR ❑ 3 DIESEL UNLEADED ❑ 6 AVIATIONGAS 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT 1b PREMIUM ❑ 4 GASAHOL ❑ 7 METHANOL UNLEADE❑ 3 CHEMICALPRODUCT E] 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED D O 99J OTHER (DESCRIBEIN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C,A.S.0: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.3,AND C,AND ALL THAT APPLIES IN BOX D AND A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 0 UNKNOWN SYSTEM J—*L 2 SINGLE WALL 714 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK 1 BARE STEEL F-12 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL I5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 1W% METHANOL COMPATIBLE WIFRP (P#mayTM9t) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UN04OWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYO LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ e UNLINED �/4-UUNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 V RAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 5 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 IF APPLICABLE �✓ A. SYSTEM TYPE A U / SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 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)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER 0. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TK3HTNES3 TESTING ❑ 3 INTERSTITIAL 99 OTHER MONITORING ❑ Y.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING 1A\\,V\\ ❑ 6 TANK TESTING ❑ 7 INTERSTITIALMOMTORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 98 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED GUANTITY OF 3.WAS TANK FILLED WITH YES ❑ 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 APPLICANTSNAME DATE /� (RRINTED♦SiGNATURfI f/_J�� LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW /r COUNTY# JURISDICT*N# FACILITY# TANK# STATE LD.# Lul (J U PERMITNUMBER PERMIT APPROVED BY/DAT PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH Tu-LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STI-AGE TANK REGULATIONS 1 �� FORME (12-91) FOR0�118P6