BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

N ..r STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD .m� UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B 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 F-14 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE —f 18 TANK REMOVED I DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 9 1496 galid filkCL— DG + I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MC/DAYNEAR) D. TANK CAPACITY IN GALLONS: ILTANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A DC 1 1 MOTOR VEHICLE FUEL F-14 OIL B. C. 1a REGULAR UNLEADED [—] 3 DIESEL ❑ 6 AVIATION GAS /❑— 2 PETROLEUM ❑ BO EMPTY 1 PRODUCT ❑ 1b PREMIUM UNLEADED E] 4 GASAHOL ❑ 7 METHANOL ❑ is MIDGRADE UNLEADED E::] 5 JET FUEL ❑ 8 MBS ❑ 3 CHEMICALPRODUCT EJ 95 UNKNOWN ❑ 2 WASTE 2 LEADED ❑ 99 OTHERICESCRIBEINITEMD.BELO'WI D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTAGE STORED C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B.AND C.AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR UNER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM F<2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK X 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary TMII) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER UNED F-12 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING J( 8 UNLINED ❑ 95 UNKNOWN ED 89 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NOX D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION NONE E:] 95 UNKNOWN [::199 OTHER E.SPILL AND OVERFILL,etc. DROP 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 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A& SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A. BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODICPROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION [D' KcK m ME Dale ❑2 ISE 3MK W!UI ❑3 carrt AWS IN1ERSi ❑4 ELECT NC Ura: E::]5 AU MA=PUMP 98 OTHER _/ �n OETECfCP TESTING NONigiulG LAK 9ETECTCR SNUI60KN V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCILIATIONUAL ORY ❑ 3 VADOZE MONITORING E] 4 AUTOMATIGAUGING MONITORING TANK ❑ 5 GROUND MONTORINGTER F-1 ANNUALTANK 6 TESTING ❑ T MONITORING INTERSTITIAL O 8 SIR ❑ 9 TANK GAUGINGAL ❑10 MOTESTINGHLY TANK 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIM D DATE LAST USED O/DAYA'R) 2.ESTIMATED QUANTITY OF ��1� 3.WAS TANK FILLED WITH YES ❑ G 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 (PRINTW d SIGNATURE) 7✓ LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW -1. COUNTY# JURISDICTION# FACILITY# STATE I.D.# = E PERMIT NUMBER PERMIT APPROVED BY/OATE PERMIT EX MM*R VATE� 71 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 PLAN. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORMS (6-95)