BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA �../ STATE WATER RESOURCES CONTROL BOARD 49 dam' UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B ;A ,., I COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ON SITE ONE ITEM 2 INTERIM PERMIT O 4 AMENDED PERMIT S TEMPORARY TANK CLOSURE B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.a Unknown B. MANUFACTURED BY: Unknown C. DATE INSTALLED(MO/DAYNEAR) Unknown D. TANK CAPACITY IN GALLONS: *10n g2llons II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. p ® 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1a REGULAR UNLEADED ❑ 3 DIESEL [:] S AVIATIONGAS F-12 PETROLEUM 80 EMPTY ® 1 PRODUCT ❑ lb PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL El 1C MOORAGE UNLEADED O 5 JETFUEL 8 M85 3 CHEMICALPRODUCT 95 UNKNOWN ❑ 2 WASTE ® 2 LEADED Q 99 OTHER(DESCRIBEN CEMD.BELOW( D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.a III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,BAND C.AND ALL THAT APPLIES IN BOX DME)E A. TYPE OF ❑ 1 DOUBLE WALL F-1 3 SINGLE WALL WITH EXTERIOR LINER ED 5 INTERNAL BLADDER SYSTEM O 95 UNKNOWN SYSTEM ® 2 SINGLE WALL Q 4 SINGLE WALL IN A VAULT O 99 OTHER B. TANK ® I BARE STEEL O 2 STAINLESS STEEL F-1 3 FIBERGLASS O 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL O 5 CONCRETE O 8 POLYVINYL CHLORIDE F-� 7 ALUMINUM E::] 8 100% METHANOL COMPATIBLE W/FRP (Primary Talk) O 9 BRONZE O 10 GALVANIZED STEEL ❑ 95 UNKNOWN 99 OTHER C.INTERIOR ❑ I RUBBER LINED O 2 ALKYD LINING ❑ 3 EPDXY LINING 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING B UNLINED ❑ 95 UNKNOWN 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— D.EXTERIOR F-1 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION El 91 NONE O 95 UNKNOWN B9 OTHER E.SPILL AND OVERFILL,BIC. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES NO STRIKER PLATE YES NO DISPENSER CONTAINMENT YES_ NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A Y) I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLEPIPING A U 99 OTHER B. CONSTRUCTION A 4) 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A O 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 8 CONCRETE A U 7 STEEL W/COATING A U B 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION1 MEcRA ME" 2 tai TK.MMi55 3 Xa9Nw S iWERSM& 4 EIMMMIC INE 5 AIROMATC Plan f..-� ❑ DETECTOR ❑ TESTW ❑ MOMTGMNG UE"DETECTOR ❑ SHaOGWH ❑ 99 OTHER V.TANK LEAK DETECTION 1 VISUAL CHECK ❑ 2 TANK RECONCILIATION ANUAL INVENTORY ❑ 3 MONIITORING OZE ❑ 4 GAUGING AUTOMATIC TANK ❑ 5 GROUND MONITORING TESTING WATER B TESTING ❑ 7 NC�OPNl IT7TNOq,NUC9INTERSTITIAL 8 SIR E] 9 WE K LA MANGY UAL �10 MOTESTINGHLY TANK ® 95 UNKNOWN D 99 OTHER Vi.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATEDa ffkh4S7�SED(MO/DAY/YR) 2 ESTIMATED QUANTITY OF 3.WAS TANK RLLED WITH YES NO SYI UII�LUWLL SUBSTANCEREMAINING UnknownGALLONS INERT MATERIAL7 ❑ Jf'� THIS FORM HAS BEEN COMPLETED UNDER ENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME ( Thr ent for Tri Star Homes, LLC DATE 5/21/97 (PRINTED a SIGNATURE) LOCAL AGENCY USE NLY THE STATE I.D.NUMBER IS C POSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION a FACILITY# TANK# UU STATE I.D.# m (p PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLIr"'ON-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FO-M C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT F FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THF _RGROUND STORAGE TANK REGULATIONS FORM B ("S)