BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA `i STATE WATER RESOURCES CONTROL BOARD "y e UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B �� COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ON SIT ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNO / A OWNER'S TANK I.D.# 31— 0 -0j (//B. MANUFACTURED BY: VK C. DATE INSTALLED(MOIDAY/YEAR) i9y D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. AKAT 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C, ❑ 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS �❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 10 PREMNM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 1-1tiZL 2 i DQ8 M85 E UNLEADED 5 JET FUEL ❑ ❑ 89 OTHER(DESCRIBE IN REM D.BELOW) D. IF(AI)IS NOT MARKED, ENTER NAME OFSUBSTANCE STORED C.A-S.#: III, TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES&B,AND C,AND ALL THAT APPLIES IN BOX D AND A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR UNER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ BB OTHER B. TANK 1 BARE STEEL O 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 (PdMaq Tm2) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD LINING �❑ 3 EPDXY LINING E:] 4 PHENOLIC LINING LINING OR F—] 5 GLASS UNING ❑ 6 UNLINED lyl 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 10D% METHANOL] YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION91 NONE �95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,etc. SPILLCONTAINMENT I STALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES NO ST KERPLATE YES_ NO_ DISPENSER CONTAINMENT YES_ NO_ IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE AWSUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLEMPING A U 99 OTHER S. CONSTRUCTION A 1 INGLE WALL A U 2DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A(WBARE 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 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 MECKN ME LEAK �2 UME TIBRrras. ❑3 coxn..INiERsnnLL ❑4 TUxm URE ❑s Auraunc Pu#P 89 OTHER OE mm mma MpWTq LEAK OEn:tTOA '.WDZ V,TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL RECONCINVENTORY ❑ION 3 VADOZE ❑ 4 AUTOGAUGMATIC C TANK ❑ 5 GROUND MONITOWATER ❑ 8 NG ANNUNLGTANK ❑ 7 MONITORING INTERSTITIAL ❑ B SIR ❑ 9 WEEKLY TANK GAUGING ❑10 MONTHLY TANK 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED DATE UST USED(MO/DAV/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH �- SUBSTANCE REMAINING U9& GALLONS INERTMATERIAL7 YES NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME Al DATE (PR#1TED 4 NGNATURE) ED L "1 C T}� � 12- 50 LOCAL AGENCY USE ONLY THE STATE I.D.1NULMIBJER IS COMPOSED OF THE FOUR NUMBERS BELOW cJ�J O COUNTY# JURISDICTION# FACILITY#66726 YTANK# STATE I.D.# 3 = ® In 6 PERMIT NUMBER ` 3 10 PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE IZ 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 INSTA TIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLA' 'P THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE OF 'SROUND STORAGE TANK REG"' ONS FORM B (6-95) �� `�