BILLING_PRE 2109 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA „'� '�' STATE WATER RESOURCES CONTROL BOARD m� UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B > , 1 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ,�❑y 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE lyp 8 TANK REMOVED Q 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(MO/DAY/YEAR) 1 D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A ❑ 1 MOTOR VEHICLE FUEL 4 OIL B. C, la REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ lb PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL J 2 PETROLEUM ❑ B0 EMPTY ❑ 1 PRODUCT ❑ 1<MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 MB5 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. F(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED O C.A S.N: IIL TANK CONSTRUCTION MARK ONE 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 BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER a. TANK �1 BARE STEEL E] 2 STAINLESS STEEL F] 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 10D% METHANOL COMPATIBLE W/FRP (PHIRvy Tmk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED �0 2 ALKYD LINING ❑ 3 EPDXY UNING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS UNING XI 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLEWITHWIIITH 100% METHANOL? YES_ NOx D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION gt NONE ❑ 95 UNKCWN ❑ 99 OTHER PROTECTION ❑ 5 CATHODIC PROTEcnCN SPILLC ,AINMENT NSTA D(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) E.SPILLANDOVERFILL,BIC. 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 A GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A91 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U B 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER t 1ECIINACIL LRE IFIJ( 2 111E 1gMAE5E 3 CDNRXUOUE RITERBiR11l 4 FLEDIRDXIC DNE 5 AVTOENTIC FLAW gg OTHER D. LEAK DETECTION ❑ oETECTgI ❑ TEETIIro ❑ MoxrORNo ❑ IFAK DETECTOR ❑ gAniXlwx V.TANK LEAK DETECTION —/� ❑ 1 VISUAL CHECK JGJ 2 RECONCILIATION CILIATIONORY ❑ 3 MONIITORING ❑ 4 GAUGING MONITORING TANK ❑5 MONTORINGOUND WATER ❑ 6 TE�NGTANK ❑ 7 CON MONTINUOUS TOR NG INTERSTITIAL ❑ 8 SIR 9 TEEN WEEKLY MANUAL ❑10 TESTINGY TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3,WAS TANK FILLED WITH YES ❑ NO SUBSTAGE REMAINING GALLONS INERT MATERIAL T THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTED a SKINATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# b TANK# STATE I.D.# m PERMIT NUMBER PER MIT APPROVED BY/DATE PERMIT EXPIRATION DATE Y 11 THIS FORK MUSTSHOULD BE ACCOMPANIED BY A PLOTUCA71 FILE FTHIS FORM OOp RM WITH THE LOCAL AGENCY IMPLEMENTING TPUNLESS A CURRENT FORM A HAS BEEN FILED. FDEHGROUND STORAGE TANK REGULATIONS RM C MUST BE COMPLETED FOR THIS FORM FORM (695) �' °� �–el 99 Awe