BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARDo~'o UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B tl°' = ( COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM, MARK ONLY Q 1 NEW PERMIT Q 3 RENEWAL PERMIT Q 5 CHANGE OF INFORMATION ❑ PERMANENTLY CLOSED SI ONE REM Q 2 INTERIM PERMIT Q 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 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.# B. MANUFACTURED BY: C. DATE INSTALLED(MWAYNEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. p ❑ I MOTOR VEHICLE FUEL 4 OIL B. C, 1A REGULAR UNLEADED Q 3 DIESEL Q 6 AVIATION GAS Q 2 PETROLEUM Q 80 EMPTY Q 1 PRODUCT ❑ 1b PREMIUM UNLEADED Q 4 GASAHOL Q 7 METHANOL Q 3 CHEMICAL PRODUCT Q BS UNKNOWN �/¢'WASTE ❑ Ic MOGRADE UPLEADED Q 5 JET FUEL Q 8 MB5 Q 2 LEADED Q 99 OTHER(DESCRIBE IN ITEM O.BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OFSUBSTANCE STORED C) 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 1 DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER A. TYPE OF ��yy Q Q s INTERNAL BUDDER SYSTEM Q 95 UNKNOWN SYSTEM L10 22 SINGLE WALL Q 4 SINGLE WALL IN A VAULT Q 99 OTHER B. TANK R ' BARE STEEL ❑ 2 STAINLESS STEEL Q 3 FIBERGLASS Q 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL Q 5 CONCRETE Q 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WIFRP (P,4nm TNN) ❑ 9 BRONZE Q 10 GALVANIZED STEEL ❑ 95 UNKNOWN Q 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED Q 2 ALKYD LINING - 3 EPDXY LINING Q 4 PHENOLIC LINING LINING OR Q 5 GLASS LINING Q 6 UNLINED BS UNKNOWN Q 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— D.EXTERIOR Q I POLYETHYLENE WRAP Q 2 COATING Q 3 VINYL WRAP Q 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE Q 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,MC. SPILL CONTAINMENT INSTALLED n ) 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 U 1 SUCTION A U 2 PRESSURE UoA GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 UNED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A 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 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE WAFRP PROTECTION A U 8 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION1 L4sOuwcu UK lFAlt 2 UK TBRRES4 3 wrm WS Im inS =m UNE U IC w �/ ❑ oE1EcrCR TE3THo Mx4Tonw9 ❑4 aEtTAX wTEcron ❑5 AsNUToow9 99 OTHER V,TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL RECONCILIATION MONITORING ❑ 3 MODOZE NIITORING E:] 4 AUTOMATGAUGING MONITORING TANK Q5 GROUND MONTORINGTER ❑8 TESTING NK ❑ 7 MONITORING INTERSTITIAL Q 8 SIR ❑ 9 WEEKLY MANUAL ❑10 MONTHLY TANK ❑ 95 UNKNOWN % OTHER TANK GAUGING TESTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATE DATE T USD( YNR) 2.ESTIMATED QUANTITY OF -!�\ 3.WAS TANK FILLED WITH YES Q NO SUBSTANCE REMAINING � [!GALLONS INERT MATERIAL? zrj THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME \ DAT (PRNTB3 A 61G WAE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.Dl m PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPI(CATION-FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLO- FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING' 'RGROUND STORAGE TANK REGULATIONS FORM 8 (6-95) `�