BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

ffrATEOFDAUFORMA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B . . ' COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM, MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ONE REM 2 INTERIM PERMIT ❑ 5 �NGE INFORMATION ❑ w O 4 AMENDED PERMIT ❑ 9 TEMPO7 PERMANENTLY OLD D ITE MRY TANK CLOSURE O A TANK REMOVED I LJ DBA OR FACILITY NAME WHERE TANK IS INSTALLED: /31� � I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.I I B. MANUFACTURED BY: \ir C. DATE INSTALLED(MQ�DAYA'EAR) ICGf� -' D. TANK CAPACITY IN GALLONS: ILTANKCONTENTS IFA.I IS MARKEOCOMPLETE ITEM C. A. RA 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C L pEGUNLEUUR 3 DIESEL ]u� 2 PETROLEUM a Bp EMp7Y 1 PRODUCT a Ib PREMI MD 4 GASAHOL O SAVIATION GAS ❑ 3 CHEMICALPRODUCT ANOL ❑ 95 UNKNOWN ❑ 2 WASTE 2 NLELEAAED 5 JET FUEL O ❑ 99 OTHER (DESCRIBE IN ITEM D. LOW) D. IF(p.l)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S. III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C.AND ALL THAT APPLIES IN BOX D ANDE A. TYPE OF I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER S. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD WI FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ S POLYVINYL CHLORIDE ❑ 7 ALUMINUM 6 100% METHANOL COMPATIBLE WIFRP (P6mvyTmk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN 99 OTHER ❑ 1 RUBBER LINED 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING C.INTERIOR 7A 5 GLASS LINING ❑ B UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 10M METHANOL YESX NO_ D.CORROSKON ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP R-A 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE O95 UNKNOWN r 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) ilt OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) q� IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A OR 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(o� 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION W1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ MNMr0gING ❑ 99 OTHER V.TANK LEAK DETECTION A� ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION 3 VADOZE MONITORING I,7�I 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ Bt NONE `❑�95 UNKNOWN ❑ W OTHER VI.TANK CLOSURE INFORMATION I.ESTI M TE UST USED(MOIDAYNH) 2.ESTIMATED OUANTITY OF 3.WAS TANK FILLEOWITH YES ❑ NO ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? THISF6RM eH.A�S9�LBEETY_COMPLETED UNDER PENAL YY OF PERJURY,AND TO THE BEST OF MYKNOWLEDGE, IS TRUE AND CORRECT APPLICANTSNAME DAq LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY 9 JURISDICTION I FACILITY 9 TANK x STATE I.D.# m 110 d (0 10 11&P 1-91 PERMIT NUMBER PERMITAPPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED I I Y7 FILE THIS FORM WITH THE.I OCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAME TANK REGULATIONS FORM (1291) F09111348416