Laserfiche WebLink
STATE OF CALIFORNIA `•c <br /> STATE WATER RESOURCES CONTROL BOARD <br /> U DERGROUND STORAGE TANK PERMIT APPLICATION • FORM <br /> C PLETE A SEPARATE FORM FOR EACH TANK SYSTEM , /`■ <br /> MARK ONLY NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ONSITE V I <br /> ONE ITEM 2 INTERIM PERMIT d AMENDED PERMIT C 8 TEMPORARY TANK CLOSURE 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK 1.D.# D S. MANUFACTURED BY: G <br /> C. DATE INSTALLED(MOIOAV/YEAR) D. TANK CAPACITY IN GALLONS: <br /> II.TANKCONTENTS IFA-11S MARKED.COMPLETE ITEM C. — <br /> A. F7 1 MOTOR VEHICLE FUEL Q d OIL B. C. 0 IAUN U LAR ED 3 DIESEL 6 AVIATKNIGAS <br /> 4 GASAHOL �--I <br /> O 2 PETROLEUM O 80 EMPTY O 1 PROWCT Q IbUN EADED 5 JETFUEL 7 METHANOL <br /> Q 3 CHEMICALPRODUCT Q 95 UNKNOWN O 2 WASTE a 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(AI)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.# <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOX D AND <br /> A. TYPE OF O I DOUBLE WALL C 3 SINGLE WALL WITH EXTERIOR LINER C 95 UNKNOWN <br /> SYSTEM Q 2 SINGLE WALL Q A SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER <br /> B. TANK 1 BARE STEEL O 2 STAINLESS STEEL 3 FIBERGLASS CI d STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL 5 CONCRETE 6 POLYVINYL CHLORIDE Q 7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP <br /> (PdmuyTank) 9 BRONZE O 10 GALVANIZED STEEL Q 95 UNKNOWN 20 OTHER <br /> I RUBBER LINED a 2 ALKYD LANG O 3 EPDXY LINING 6 PHENOLIC LINING <br /> C.INTERIOR 5 GLASS LINING 0 6 UNLINED 95 UNKNOWN 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? VES_ NO— <br /> D.CORROSION O I POLYETHYLENE WRAP Q 2 COATING O 3 VINYL WRAP O d FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION Q 5 CATHODK:PROTECTION Q 91 NONE O 95 UNKNOWN a 9B OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTICN EQUIPMENT INSTALLED(YEAR) <br /> IV. PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND.BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U N OTHER <br /> 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 <br /> C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U d 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 C I AUTOMATIC LINE LEAK DETECTOR [:] 2 LINE TIGHTNESS TESTING O 99 OTHER <br /> MONRORING <br /> V.TANK LEAK DETECTION <br /> 1 VISUAL CHECK 2 INVENTORY RECONCILIATION 3 VADOZE MONITORING d AUTOMATIC TANK GAUGING O 5 GROUNDWATER MONITORING <br /> 6 TANK TESTING 7 INTERSTITIAL MONITORING O 91 NONE 95 UNKNOWN 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MOA)AV/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES a NO O <br /> SUBSTANCE R EMAINING GALLONS INERT MATERIAL? <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANT'S NAME DATE <br /> (PRINTED A SIGNATURE( <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK# 12 <br /> STATE I.D.# l = PC Z I I I I t C� <br /> PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE <br /> FORM B (7-911 THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. ��-/M/��/1 7 <br /> _.. �� FORgLj / <br />