Laserfiche WebLink
f <br /> STATE OF CALIFORNIA a'`h o •��''• <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br /> COMPLETE A SEPARATE FORM FOR EA ANK SYSTEM <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ONSITE <br /> ONE ITEM F7 2 INTERIM PERMIT Q 4 AMENDED PERMIT 06 TEMPORARY/TANK CLOSURE a 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: c,9 <br /> i <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.t �� S. MANUFACTURED BY: Ic- <br /> C DATE INSTALLED(MO/DAV/IEAR) L D. TANK CAPACITY IN GALLONS: <br /> ILTANKCONTENTS IFA-11SMARKED,COMPLETE ITEM C. <br /> 1 MOTOR VEHICLE FUEL 4 OIL B. C, 0 /aUREGULARD e 3 DIESEL � 9 AVIATIONGAS <br /> A. 4 GASAHOL <br /> 2 PETROLEUM 80 EMPTY 1 PROOl1CT ❑ 1b NLE".0 D 5 JET NEL 7 METHANOL <br /> 3 CHEMICAL PRODUCT Q 95 UNKNOWN 2 WASTE 2 LEADED 99 OTHER (DESCRIBE IN ITEM D.BELOW) <br /> D. IF(&I)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.t: <br /> 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOX D AND <br /> A. TYPE OF ❑ BLE WALL 3 SINGLE WALL WITH EXTERIOR LINER Q 95 UNKNOWN <br /> SYSTEM 2 LE WALL E] 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER <br /> B. TANK EY'l BARE STEEL 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL O 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE 7 ALUMINUM 8 100% METHANOL COMPATIBLE WIFRP <br /> (PrimaryTank) 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> 1 RUBBER LINED 2 0 LWNG 3 EPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR <br /> LINING5 GLASS LINING IrJ-�/6 UNLINED F-195 UNKNOWN 99 OTHER <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO— <br /> D.CORROSION <br /> 1 POLYETHYLENE WRAP ATING 3 VINYL WRAP 4 FIBERGLASS REINFORCED-PLASTIO <br /> �_----' <br /> PROTECTION [�] 5 CATHODIC PROTECTION = 91 NONE 95 UNKNOWN 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> IV.PIPING INFORMATION CI LE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U SUCT A U 2 PRESSURE A U 3 GRAVITY A U 90 OTHER <br /> B. CONSTRUCTION A U LE. A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A URE A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 5 CONCRETE A U 7 STEEL W/OOATNG A U 0 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 90 OTHER <br /> D. LEAK DETECTION 01 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING 311011RTTIALORIG w OTHER <br /> V.TANK LEAK DETECTION <br /> J 1 VISUAL CHECK Q 2 INVENTORY RECONCILIATION 0 3AI ZE MONITORING [:] 4 AUTOMATICTANK GALK31NG O 5 GROUND WATER MONITORING <br /> S TANK TESTING O 7 INTERSTITIAL MONITORING 91 NONE E] 95 UNKNOWN Q 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE UST USED(MO/DAV/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO <br /> �Z� SUBSTANCE REMAINING CA INERT MATERIAL IJ <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 9 JURISDICTION t FACILITY R TANK• <br /> STATE I.D.# ® fE= <br /> PERMITNUMBER PERMIT APPROVED BYAAATE PERMIT EXPIRATION DATE <br /> /0/-. <br /> FORM B (7.91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. /�• "� <br /> WNOON&RS <br />