BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD sy ° UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B ( COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 3535 9 i I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN A OWNERS TANK I.D.• B. MANUFACTURED BY: -3 1 C. DATE INSTALLED(MO/DAY/YEAR) �(/ry,,`r� D. TANK CAPACITY IN GALLONS: O II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1e REGUI?A UNLEADm 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 1a PREMIUM UNLEADED 4 GASAHOL ❑ 7 METHANOL ❑ Ic MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(A1)IS NOT MARKED, ENTER E OF SUBSTANCE STORED C A S.# III. TANK CONSTRUCTION ZkRK ONE ITEM ONLY IN BOXES A.3,AND C.AND ALL THAT APPLIES IN BOX D AND A. TYPE OF ❑ i DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINEA ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM E:] 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL F-13 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL E] 5 CONCRETE 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 1 METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COA G ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,BTO. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES_ NO_ IKER PLATE YES_ NO_ DISPENSER CONTAINMENT YES NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U I NDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL 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 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑1 #ECRU ME IFAIc ❑2 ME nc9RESS ❑3 co#n9CWS IKIEMS 4 EMMMIC URE ❑5 AIrteMAnc PUM= ❑ � oTH6R IIETEColl TEEING MGNiOnNG LEAN OETECnIR SHUIDGWN V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RMANUAL LIATIONORY ❑ 3 MOTORING ❑ 4 GA OMG C TANK ❑5 MONITORINGGROUND TER ❑ 8 TIES TING AL TANK ❑ 7 MONITORING INTERSTITIAL ❑ B SIR ❑ 9 TANK GAUGING ❑10 MONTEON STI LY TANK ❑ 95 UNKNOWN ❑9B OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MOIDAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FTLLED WITH YES O NO❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRP1iF0661GNANRE) (+� LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW Z oZ O D� COUNTY# JURISDICTION# FACILITY# TANK# STATE I.Dl m = I I I FT__Fl 111 8161011013J PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PL# 9LE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UP--GROUND STORAGE TANK REGULATIONSIO��i/ FORM B (6.95) 1i �� // 5 ,y- 9& Al