Laserfiche WebLink
STATE OF CALIFORNIA `� •� <br /> STATE WATER RESOURCES CONTROL BOARD i ¢ <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> MARK ONLYQ NEW PERMIT F7 3 RENEWAL PERMIT F7 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ON SITE <br /> ONE ITEM 22 INTERIM PERMIT O 4 AMENDED PERMIT E:] 6 TEMPORARY TANK CLOSURE O 8 TANK REMOVED Z_ <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 0&:�) E. rem -1 <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK 1.D.# T B. MANUFACTURED BY: K k <br /> C. DATE INSTALLED(MOIDAYNEAR) l'Ir 7 cl D. TANK CAPACITY IN GALLONS: Z QO U <br /> ILTANKCONTENTS IFA-1 ISMARKED,COMPLETE ITEM C. <br /> REGULAR <br /> A. <br /> 'IMOTOR VEHICLE FUEL 4 OIL B. C. Q 18UNLEADED <br /> 3 DIESEL O g AVIATION GAS <br /> r7 2 PETROLEUM O g0 EMPTY1 PRODUCT O Ib PREMIUM 4 GASAHOL O 7 METHANOL <br /> 0 3 CHEMICAL PRODUCT O 95 UNKNOWN O 2 WASTE 2 LEADEDUNLEADE99 JOTHERL(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 O AND <br /> A. TYPE OF O i qqlRUE WALL O 3 SINGLE WALL WITH EXTERIOR LINER O 95 UNKNOWN <br /> SYSTEM2 SINGLE WALL 0 4 SECONDARY CONTAINMENT (VAULTEDTANK) O 99 OTHER <br /> B. TANK F--j 1 RARE STEEL ❑ 2 STAINLESS STEEL F-1 3 FIBERGLASS 0 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL F—] 5 CONCRETE F--] 6 POLYVINYL CHLORIDE 7 ALUMINUM 0 9 100% METHANOL COMPATIBLE W/FRP <br /> (PdmgryTmk) ❑ 9 BRONZE D 10 GALVANIZED STEEL '95 UNKNOWN O 99 OTHER <br /> O 1 RUBBER LINED O 2 ALKYD LINING O 3 EPDXY LINING O 4 PHENOLIC LINING <br /> C.INTERIOR O 5 GLASS LINING 0 6 UNLINED [�]-95 UNKNOWN 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 10D%METHANOL? YES_ NO— <br /> D.CORROSION 1 POLYETHYLENE WRAP O 2 COATING 0 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION Q 91 NONE L;�W UNKNOWN 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION p n PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A U 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 6 CONCRETE A U 7 STEEL W/COATING A U 8 ll d METHANOL COMPATIBLE WIFRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A 5 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION Efr 1-AUTOMATIC LINE LEAK DETECTOR ] 2 LINE TIGHTNESS TESTING O 3 moNrtoRING 99 OTHER <br /> V.TANK LEAK DETECTION <br /> 1 VISUAL CHECK 2 INVENTORY RECONCILIATION 3 VADOZE MONITORING a 4 AUTOMATIC TANK GAUGING O 5 GROUND WATER MONITORING <br /> O 6 TANK TESTING O 7 INTERSTITIAL MONITORING 91 NONE 95 UNKNOWN O 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES D NO <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL? <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME DATE <br /> (PRIMED&SIGNAT RO <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# I-FACIt'f'I # TANK# <br /> STATE I.D.# Z 3 5 5 3 S S 3 d <br /> PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE / _0;-,,pe 7�' <br /> THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM B (12-91) <br /> FOROWa ER <br />