Laserfiche WebLink
STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD �V <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br /> ,� IT <br /> COMPLETE A SEPARATE FORM FOR CH TANK SYSTE <br /> 15M. <br /> MART(ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSE ONSITE <br /> ONE ITEM 2 INTERIM PERMIT O 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE O 8 TANK REMOVED <br /> DBA OR FACILITY kAME WHERE TANK IS INSTALLED: 1p3 J <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.# S. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAYNEAR) I D. TANK CAPACITY IN GALLONS: �® <br /> ILTANKCONTENTS IFA-119 MARKED,COMPLETE ITEM C. <br /> REGULARA 5Y GASAH 1 MOTOR VEHICLE FUEL 4 OIL B. C. ❑ 1aUNLEADEO 3 a AVIATION OAS <br /> f�'� 4 ASAHOL <br /> 0 2 PETROLEUM O 80 EMPTY �1 PRODUCT E 1b PREMIUM 7 METHANOL <br /> UNLEADED 5 JET FUEL <br /> O 3 CHEMICAL PRODUCT 95 UNKNOWN 0 2 WASTE 0 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALLTHAT APPLIES IN BOX D AND <br /> A. TYPE OF F7 1 DOUBLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM x2 SINGLE WALL Q 4 SECONDARY CONTAINMENT (VAULTED TANK) O 99 OTHER <br /> B. TANK X1 BARE STEEL O 2 STAINLESS STEEL O 3 FIBERGLASS D 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL O 5 CONCRETE 9 POLYVINYL CHLORIDE a 7 ALUMINUM O 8 100% METHANOL COMPATIBLE W1FRP <br /> (PrimaryTank) 09 BRONZE O 10 GALVANIZED STEEL. 95 UNKNOWN ED 99 OTHER <br /> 0 1 RUBBER LINED ED 2 ALKYD LINING 3 EPDXY LINING F] 4 PHENOLIC LINING <br /> C.INTERIOR O 5 GLASS LINING6 UNLINED O 95 UNKNOWN E] 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WI H 100%METHANOL 7 YES_ NO— <br /> D.CORROSION F--j 1 POLYETHYLENE WRAP E 2 COATING O 3 VINYL WRAP O 4 FIBERGLASS REINF RCID PLAST* <br /> PROTECTION Q 5 CATHODIC PROTECTION D�J:'91 NONE O96 UNKNOWN W OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) tk* OVERFILL PREVENTION EOUIPMENT INSTALLED(YEAR) <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTIONU 2 PRESSURE A U 3 GRAVITY A V 99 OTHER <br /> B. CONSTRUCTION AU 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A V 95 UNKNOWN A S 99 OTHER <br /> C. MATERIAL AND A p 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 9 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A V 99 OTHER <br /> D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING ❑ 3 INOT EIC 099 OTHER <br /> V.TANK LEAK DETECTION <br /> �T <br /> u 1 VISUAL CHECK �9 2 INVENTORY RECONCILIATION O3 VADOZE MONITOR8IS F] 4 AUTOMATIC TANK GAUGING E:] 6 GROUND WATER MONITORMA <br /> O 6 TANK TESTING X0'`7 INTERSTITIALMONITORING 71 9/ NONE O 95 UNKNOWN O 99 OTHER <br /> VI.TANK CLOSURE INFORMATION. <br /> 1.UTIMATEDDAT T L41ED(MO,DAYNN B.ESTIMATED QUANTITY OF I WAS TANK FILLED WITH YES MD � <br /> SUBSTANCE REMAINING CALLOW I INERTMATERML7 <br /> THIS FORM HAS BEEN COMPLETED LWDER PENALTY OF PERJURY,AND TO THE BEST OF AIA'KNOWLEDGE, IS TRUE Alp COROWT <br /> APPLICANT'S NAME DATE <br /> (PRINTED 6 M6RATWi9I <br /> LOCAL AGENCY USE ONLY TME STATFLD.RYMER IS COMPOSED OF THE FOUR NUMBERS BELOW Rec. T P O-13 I S SS <br /> COUNTY# JURISDICTION# FACILITY �TANK# <br /> STATE I.D.# <br /> PERMITNUMBER PFRM IT APPROVED BYIDATE PERMIT EXPIRATION DATE <br /> FORM B (7.91) TH16 FORM MUST BE ACCOMPAtiI)BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS 13111101S0. � -I , <br /> v id" A� <br />