BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

...+ STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. 914` � 1 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL ED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 3535 E, Y � I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNERS TANK 1.D.♦ 3 S. MANUFACTURED BY: C. DATE INSTALLED(MOIDAY/YEAR) (.(/�� D. TANK CAPACITY IN GALLONS: O /� ILTANK CONTENTS IF A•1 IS MARKED.COMPLETE ITEM C. V A 1 MOTOR VEHICLE FUEL ❑ 0 OIL IL�y C, to REGULAR UNLEADED 3 DIESEL [—] 6 AVIATIONGAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1�} 1 PRODUCT l:PREMIUM UNLEADED d GASAHOL C-] 7 METHANOL /— IC MIOGRADE UNLEADED 5 JET FUEL [:] B M6S ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 OTHER MESCR®EW NEM D.BEUM D. IF(A1)IS NOT MARKED. ENTER E OF SUBSTANCE STORED C.A S.N: III. TANK CONSTRUCTION NK ONE ITEM ONLY IN BOXES A.S.AND C.AND ALL THATAPPUES W BOX O AND E A. TYPE OF ❑ I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 0 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 0 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Plimvy T-k) ❑ 9 BRONZE 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER UNEDAWITH D LINING ❑ 3 EPDXY LINING ❑ d PHENOLIC LINING LINING OR ❑ 5 GLASS LINING KED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBMETHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COA G ❑ 3 VINYL WRAP ❑ d FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,etc. SPILL CONTAINMENT INSTALLED(YEAR) OVERRLL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES_ NO_ —*KEFI YES_ NO— DISPENSER CONTAINMENT YES NO IV. PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF NOERGROUND.BOTH IFAPPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U s FLEXIBLEPIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U Z 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 d FIBERGLASS PIPE CORROSION A U S ALUMINUM A U 6 CONCRETE A U STEEL W/COATING A U B 100% METHANOL COMPATIBLE WA=RP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑1 1L LAI LEAK ❑2 hg IIGHItaF55 [:]I�M mTASmuL N BECI9wIIeur+E a s enc ww ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCILIATIONNUAL MONITORING ❑ 3 MO BORING ❑ GA OMA( TANK. ❑5 MOON TORING OUND WATER ❑ e TESTINGANNUAL TANK ❑ 7 CONTINUOUS INTERSTITIAL ❑ 8 SIR ❑ 9 WEEKLTANK Y ❑10 MO rINGTI LY TANK ❑ 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) t.EST DATE q LAST U ( Y/YR)174 laz 2.ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITE MEH YES ED ❑ SUBSTANCE REMAINING GALLONS INERTMATERIAL? THIS FORM HAS BEN CbMPI ETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNERS NAME DATE (PRINTED A 6KNATURO LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW Ree-,, ca ' D COUNTY k JURISDICTION N FACILITY A TANK k STATE LDJ m = I I I 1 1126101021 2 PERMIT NUMBER PERMT APPROVED BYIDATE PERMT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT `. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING T' GROUND STORAGE TANK REGULATIONS ,N FORME (6-95) -4 '/ .5- 96 W •"�