BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATEOFCAUPORNA - ` STATE WATER RESOURCES CONTROL BOARD W`w , a UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B g- ,,,. ,� COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM �� '� MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT F-14 AMENDED PERMIT ❑ B TEMPORARY TANK CLOSURE Q 8 TANK REMOVED y DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.s B. MANUFACTURED BY: C. DATE INSTALLED(MOCAY/YEAR) D. TANK CAPACITY IN GALLONS: ILTANKCONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A ❑ 1 M R VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1a REGUL R B 3 DIESEL ❑ 6 AVIATION GAS ❑ TROLEUM ❑ 80 EMPTY I PRODUCT ❑ 1eUN UNLEADED 5 FUEL ❑ 7 METHANOL 3 CHEMICAL PRODUCT ❑ 0.5 UNKNOWN ❑ 2 WASTE 2 LEADED 9B OT4 GASHER (DESCRIBE N ITEM D.BELOW) D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.•: so I4 M G r`J NnS�.d� III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,8,AND C,AND ALL THAT APPLIES IN BOX D AND A. TYPE OF ❑ DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ BARE STEEL ❑ 2 STAINLESS STEEL [:] 3 FIBERGLASS E::] 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC MATERIAL S CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PdmaryTu6Q ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 96 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 D LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR 5 ASS LINING 6 UNLINED F7GL ED ❑ 06 UNKNOW ❑ 99 OTHER LINING ✓ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO D.CORROSION ❑ I POLYETHYLENE WRAP ❑�/IOATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED MASTIC PROTECTION ❑ S CATHODICPROTECTION L'] 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U A U 99 OTHER B. CONSTRUCTION A U / SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A V 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 0 CONCRETE A U 7 STEEL WI COATING A U 8 10D% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A { yLJ p wQ D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ MONRORING � nJ V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ AOOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VLTANK CLOSURE INFORMATION 1.ESTIMATED DATE UST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILED WITH YES NO❑ 8' ZZ Y SUBSTANCE REMAINING C7 GALLONS INERTMATERIAL7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT APPLK:ANTS NAME DATE Imww o SKNATtJm LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY 8 JURISDICTION 8 FACILITY s TANK s bl H l/-/0 STATE I.D.# W FT-T-1 (- 7 PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE (o Y l5 FORM B (7.91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. `!� R01101198D