Laserfiche WebLink
A� 'F 60 <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD +�- l�D <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B W "° <br /> / y C�1,�0„M.�.D <br /> l/ COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> MARK ONLY O 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ED 7 PERMANENTLY CLOSED ONSITE <br /> ONE ITEM 0 2 INTERIM PERMIT 4 AMENDED PERMIT 0 6 TEMPORARY TANK CLOSURE 0 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: _ kT.['4' <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNERS TANK I.D.s 0-3 B. MANUFACTURED BY: O G <br /> C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: <br /> ou <br /> 11.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. <br /> 1 MOTOR VEHICLE FUEL O 4 OIL 8. / C. 1aUN FADED 3 DIESEL 0 6 AVIATION GAS <br /> A / u 4 GASAHOL <br /> 2 PETROLEUM O 80 EMPTY Lie1 PRODUCT O 1bUN EAIUM 5 JET FUEL 7 METHANOL <br /> O 3 CHEMICALPRODUCT O 95 UNKNOWN O 2 WASTE 0 2 LEADED O 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.is <br /> Ill. TANK CONSTRUC ION MARK ONE ITEM ONLY IN BOXESA,B,AND C.AND ALL THAT APPLIES IN BOX D AND <br /> A. TYPE OF 1 DOUBLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM Q 2 SINGLE WALL Q 4 SECONDARY CONTAINMENT (VA LTEDTANK) 0 99 OTHER <br /> 1 BARE STEEL E] 2 STAINLESS STEEL 3 FIBERGLASS E] 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B. TANK O 6 POLYVINYL CHLORIDE 0 7 ALUMINUM O B 100% METHANOL COMPATIBLE W/FRP <br /> MATERIAL D s CONCRETE <br /> (Primary Tank) 9 BRONZE 0 10 GALVANIZED STEEL O 95 UNKNOWN O 99 OTHER <br /> O 1 RUBBER LINED 2 ALKYD LINING 3 EPDXY LINING O 4 PHENOLIC LINING <br /> C.INTERIOR 5 GLASS LINING 0 6 UNLINED O 95 UNKNOWN O 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? VES_ NO— <br /> D.CORROSION 1 POLYETHYLENE WRAP O 2 COATING O 3 VINYL WRAP FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION = 91 NONE 95 UNKNOWN O 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION p PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A 05 LINED TRENCH A U W UNKNOWN A U 9B OTHER <br /> C. MATERIAL AND A U i BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A 04 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION 01 AUTOMATIC LINE LEAK DETECTOR E 2 LINE TIGHTNESS TESTING O MONITORNO O 99 OTHER <br /> V.TANK LEAK DETECTION <br /> 1 VISUAL CHECK 0Z�PIVENTORY RECONCILIATION [:] 3 VADOZE MONITORING O 4 AUTOMATIC TANK GAUGING O 5 GROUND WATER MONITORING <br /> 0 6 TANK TESTING IL_J^I 77 INTERSTITIAL MONITORING Ej 91 NONE O 95 UNKNOWN a 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ONO 0 <br /> SUBSTANCEREMAINING GALLONS IN <br /> MATERIAL' <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME DAT <br /> (PRINTED 8SIGNATURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK# <br /> STATE I.D.# Z E v 3 <br /> PERMITNUMBER PERMIT APPROVED BY/DATE QEaWWQWWA+I8N-0ATE Z`/-� <br /> THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FILE THIS FORM WITH TUF LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM (12-91) /7t/ FOROM&R6 <br />