Laserfiche WebLink
ti <br /> STATEOFCAUFORMA w <br /> STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM BCOMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I NEN PERMIT ] RENEWAL PERMIT 1 5 CHANGE OF INFORMATION a T PERMANENTLY�CLO$ED ONSITE <br /> 2 INTERIM PERMIT � a AME <br /> NOEO PERMIT <br /> MARK ONLY 6 TEMPORARY TANK CLOSURE I TANK REMOVED <br /> ONE ITEM <br /> OBA OR FACILITY NAME WHERE TANK IS INSTALLED: <br /> V <br /> I. TANK DESCRIPTION COMP-LET E ALL ITEMS- SPECIFY IF UNKNOWN L <br /> A. BWNER'S TANK I.D. <br /> 0a. MANUFACTURED BY: O <br /> C. i <br /> D. TANK CAPACITY IN GALLONS: <br /> DATE NSTALLEp(MO/DAY/YEAR) <br /> II.TANK C EMS IFA-I ISMARKEMCOMPLETEITEMC. —, taREGULAR 1 ] DIESEL 6 AVIATION GAS <br /> 1 MOTOR VEHICLE FUEL A OIL i B. C. UNLEADED a GASAHOL <br /> A. t PRODUCT ID PREMIUM 7 METHANOL <br /> 2 PETROLEUM CI W EMPTY ❑ UNLEADED 5 JETFUEL — <br /> CHEMICAL PRODUCT 95 UNIQNOWN 2 WASTE 2 LEADED 99 OTHER ;DESCRIBE IN ITEM 0. BELOWI <br /> D. IF(A.:)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED <br /> Q.A Ya: <br /> II. TANK CONSTRU TION MARK ONE ITEM ONLY IN BOXESA.S.ANOC.AND ALL-THAT APPLES;N8OX D AND <br /> I DOUBLE WALL ] SINGLE WALL WITH EXTERIOR LINER JI 95 UNW40WN <br /> A. TYPE OF n SECONDARY CONTAINMENT (VAULTED TANK) <br /> 99 OTHER <br /> SYSTEM L-J 2 SINGLE WALT' <br /> r- —� n STEE_ CLAD WI FI8ERGlASS REINFORCED PLASTIC <br /> 1 BASE STEEL ❑ 2 STAINLESS STEEL I� ] FIBERGLASS — <br /> 0. TANK 5 C.;NCAETE 6 POLYVINYL CHLORIDE LJ T ALUMINON _ 6 100% METHANOL CQMPATIBIF WIFRP <br /> MATERIAL — <br /> (Primary Tank( —'I 9 3RONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> ! t RUBBER LINED <br /> u 2 ALKYD LWWG EPDXY LINING <br /> !J A PHENOLIC LINING <br /> LNT 5 GLASS LINING I18 UNLINED 95 UNKNOWN 90 OTHER <br /> IS LINING MATERIAL COMPATIBLE WITH IMY. METHANOL? YES_ NO—I POLYETHYLENE WRAP '`I 2 COATING ] VINYL WRAPtFIBERGlA9S REWFOPCEDPLASTIC u u 95 UNKNOWN 99 OTHER <br /> N 5 CATHODIC PROTECTION I� 91 NONEVERFILL <br /> SPILL CCNTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF AP-LICABLE <br /> A. SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U ] GRAVITY A U N OTHER <br /> 0. CONSTRUCTION A U I SINGLE WALL A U 2 DOUBLE WALL A D] LINED TRENCH A U 95 UNKNOWN A U 39 OTHER <br /> C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U ] POLYVINYL CHLORIDE(PVC)A s FIBERGLASS PIPE <br /> CORROSION A U S ALUMINUM A U 6 CONCRETE A U 7 STEE UNKNOWN A U 9910THER METHANOL COMPATIBLE WIFRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U rr� <br /> D. LEAK DETECTION lI I AUTOMATIC LINE LEAN DETECTOR C 2 LINE TIGHTNESS TESTING Q 3 MONRORNG U 99 OTHER <br /> V.TANK LEAK DETECTION <br /> I VISUAL CHECK 2 INVENTORY RECONCILNTION U ] VAD02E MONITORING A AUTOMATIC TANK GAUGING IuI 5 GROUND WATER MONITORING <br /> F;-a,g TANK TESTING IN iERSTITIAL MONITORING ! 91 NONE <br /> L 95 UNKNOWN 90 OTHER <br /> VI.TANK CLOSURE INFORMATION 3.WAS TANK FILLED WITH <br /> 2ESTIMATEO QUANTITY OF YES NO — <br /> i.^STIMATED DATE LAST USED(MOICAYIVR) SUBSTANCE REMAINING GALLONS INERT MATERIAL? <br /> THlS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE. IS TRUE AND CORRECT <br /> APPLICANTS NAME <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY x JURISDICTION x FACILITY x TANK x <br /> STATE I.D.* <br /> PERMIT APPROVED SYIDATE - ATE <br /> PERMIT NUMBER II <br /> THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORMA,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FILE THIS FORM WITH T"` 'AL AGENCY IMPLEMEtITING THE UNDERGROUND S"'o4 TANK REGULATIONS �R�g96 <br /> 'ORM3 '2.21) `� /�,• / <br />