BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

�eou. � STATE OF CALIFORNIA — ^�� c STATE WATER RESOURCES CONTROL BOARD ;! UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B W mcg ° COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. A ��`��°"�� MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 P ANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ S TEMPORARY TANK CLOSURE TANK REMOVED O/ DBA OR FACILITY NAME WHERE TANK IS INSTALLED: t(U/ S, /c-Q,� L o I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# B. MANUFACTURED BY: u(L s C. DATE INSTALLED(MO/OAYIYEAR) V( ift D. TANK CAPACITY IN GALLONS: (U VUv 0.A II.TANK CONTENTS IFA-11SMARKED,COMPLETE ITEM C. 1a REGULAR 3 DIESEL A u 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ UNLEADED ❑ S AVIATION GAS 4 DIESELGASAHL ❑ 2 PETROLEUM ❑ W EMPTY 1 PRODUCT ❑ 1b PR JACFADED ❑ 5 JET FUEL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED CAS#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,ANDC,ANDALLTHATAPPLIES INBOXD A. TYPE OF ❑ 1 UBLE WALL F-13 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM LE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER S. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ S POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 9 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑YD LINWG ❑ 3 EPDXY LINING 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING 8 UNLINED ❑ 95 UNKNOWN 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH IOD96 METHANOL? YES_ NO— D.CORROSION ❑ / POLYETHYLENE WRAP ❑ TING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION E:] 5 CATHODIC PROTECTKNJ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEMTYPE A U I SUCTION A U A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1GEE A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U Q RE STE A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U S CONCRETE A U 7 STEEL W/COATING A U S IOD% METHANOL COMPATIBLE W/FOP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ I AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 31NT ST IALE::] 99 OTHER MONITORING V.TANK LEAK DETECTION ❑ I VISUAL CHECK 7D,412 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ S TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(M /DAY/YR) 2.ESTIMATED OUANTITV OF 3.WAS TANK FILLED WITH YES ❑ NO / U tf3 SUBSTANCE REMAINING GALLONS INERTMATERIAL7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PLANTED&SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# �', FACILITY# TANK# TAr-fcp � STATE I.D.# 3 a PERMIT NUMBER PERMIT APPROVED BY/DATE I PERMITEXPIRATION n FORM B (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. F0RNMB-RI