BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

1-0, �j3� 3s STATE OF CALIFORNIA s, STATE WATER RESOURCES CONTROL BOARD / ANDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR CH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE 8 TANK REMOVED /1 DBA OR FACILITY NAVE WHERE TANK IS INSTALLED: Z- &I&-- el-�V I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN A. OWNERS TANK I.D.# B. MANUFACTURED B : C. DATE INSTALLED(MO/DAYIYEAR) D. TANK CAPACITY IN GALLONS: D II.TANKCON S IFA-11SMARKED.COMPLETE ITEMC. A. MOTOR VEHICLE FUEL ❑ 4 OIL S, p a REGULAR � 3 DIESEL ❑ g AVIATION GAS UNLEADED 4 GASAHOL ❑ 2 PETROLEUM ❑ BO EMPTY 1 PlmDUCT ❑ 1bUL EARED ❑ 5 JET FUEL ❑ 7 METHANOL ❑ 3 CHEMICALPRODUCT ❑ B5 UNKNOWN E::] 2 WASTE ❑ 2 LEADED ❑ gg OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.Al III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C,AND ALL THAT APPLIES IN BOX D AND A. TYPE OF ❑ 1_,WUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 520 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ / BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 INUM ❑ B 100% METHANOL COMPATIBLE W/FRP (PNmaryTenk) ❑ g BRONZE ❑ 10 GALVANIZED STEEL —L�I$/UNKNOWN O gg OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3,,5PDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING F-18 UNLINED 95 UNKNOWN W OTHER LINING 0 IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 09 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 3 GRAVITY A U 99 OTHER C' B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U M UNKNOWN A U gg OTHER �F C. MATERIAL AND A U 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 a CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 8 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 90 OTHER LgNRORING ❑ V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 8 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 85 UNKNOWN ❑ gg OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO 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 APPLICANTS NAME DATE AI 2 ✓ � 'PRINTED 6 SIGNRNHE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS STATE I.D.# COUN # JURISDICTION# F LITY# TANK# / ��v 77 1 a q I �C73 PERMIT ER ^ O PERMIT APPROVED BY/DATE T EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (12-91) x/ ,�/ `� FON061/B-R6