BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD uyd� a°o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT E] 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON ONE REM ❑ 2 INTERIM PERMIT F-14 AMENDED PERMIT ❑ S TEMPORARY TANK CLOSURE 9 TANK REMOVED 0 C DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNERS TANK 1.D.M # B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAYNEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. to REGULAR UNLEADED 3 DIESEL ❑ I AVIATION GAS A 17ta 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. L-�- C ❑ 19 PREMIUM UNLEADED ® 4 GASAL ❑ 7 METHANOL ILI 2 PETROLEUM ❑ BO EMPTY IYI 1 PRODUCT ❑ 1c MIDGRADE UNLEADED 5 JETFUEL ❑ S M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN !❑�2 WASTE ❑ 2 LEADED 99 OTHER(DESCRIBE IN REM D.BELOW) D. IF(A1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A S.III: III. TANK CONSTRUCTION OE 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 LINER ❑ 5 INTERNAL BUDDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100%METHANOL COMPATIBLE WIFRP (P07 TON ❑ 9 BRONZE 10 GALVANIZED STEEL ❑ 85 UNKNOWN ❑ 89 OTHER C.INTERIOR ❑ I RUBBER UNED 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 1 METHANOL? YES_ NO_ D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 CO NG ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION 91 NOH 95 UNKNOWN ❑ 9B OTHER PROTECTION ❑ s CATHODIC PROTEC710N ❑ ❑ SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,HIIC. DROP TUBE VES_ NO_ STRIKER PLATE YES_ NO_ DISPENSER CONTMNMENT VES_ NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR tkIF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WA A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STE A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U B CONCRETE A U 7 STEEL W COATING A U S 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTE O A U 95 UNKNOWN A U 99 ❑ TEsml9 MOMraIMl9 OTHER D. LEAK DETECTION ❑1 EMIMFFA3N4NMCNR ❑ ❑ 99 OER TC0 9ufo0xn V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RMANUAL ECONCILIATIONORY ❑ 3 MONTORING ❑ 4 GAUGING AUTOMATIC TANK ❑5 GROUND MONITORINGTER E:]B ANNUALTESTING ❑ 7 MCOONTINNUROU INTERSTITIAL ❑ B SIR ❑ 9 WEEKLTANKA MANUAL 10 MONTHLY TANK ❑ 95 UNKNOWN ❑99 OTHER ING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATEa USED( AYNR 2 ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM AS BEEN 60MPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNERS NAME DATE (PRIMED A SKMTURE) LOCAL AGENCY USE ONLY THE STATE LD.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY 9 JURISDICTION N FACILITY k TANK 9 STATE I.D.# m PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE ,Q 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 P . FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THr 1ERGROUNSTORAGE TAN REGULATIONS FORMS (G95)