Laserfiche WebLink
STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B , <br /> I� COMPLETE A SEPARATE FORM FO ACH TANK SYSTEM, <br /> MARK ONLY F7 1 NEW PERMIT <br /> Q 3 RENEWAL PERMIT t--�CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ONSITE <br /> ONE ITEM F72 INTERIM PERMIT 04 AMENDED PERMIT TEMPORARY TANK CLOSURE 8 TANK REMOVED / <br /> i If <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 12c 11 5:10'I'23iiii <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.• b S. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAY/YEAR) /�/ D. TANK CAPACITY IN GALLONS: <br /> II.TANK NTENTS IFA-1 IS MARKEO,COMPLETE ITEM C.34 RTEGULARO <br /> A. <br /> LWS <br /> VEHICLE FUEL 040 IL B. C. ❑ 1a <br /> UNLEADED ❑ 4 GASAHOL O 7 METHANOL <br /> GAS <br /> 2 PETROLEUM El So Em I PRODUC <br /> ET <br /> UNLEADE <br /> AL PRODUCT Q UNKNOWN Q 2 WASTE T 0 2 LEADED O 99 JOTHERL(DESCRIBE IN ITEM D. BELOW) <br /> DRKED. ENTER NAME OF SUBSTANCE3TORE0J'gmff 4w"6 A,C6 (1t5lW . C.A.S.#: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C.AND ALLTHAT APPLIES IN BOX D AND <br /> 1 DOUBLE WALL 0 3 SINGLE WALL WITH EXTERIOR LINER El 95 UNKNOWN <br /> A. TYPE OF 99 OTHER <br /> SYSTEM 2 SINGLE WALL Q 4 SECONDARY CONTAINMENT (VAULTED TANK) Q <br /> 1 BARE STEEL � 2 STAINLESS STEEL O3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B. TANK 5 CONCRETE 0 8 POLYVINYL CHLORIDE 7 ALUMINUM 9 100% METHANOL COMPATIBLE W/FRP <br /> MATERIAL D <br /> (Primary Tank) O 9 BRONZE F-1 10 GALVANIZED STEEL 96 UNKNOWN 99 OTHER <br /> O 1 RUBBER LINED 2 ALKYD LINING 3 EPDXY LINING O 4 PHENOLIC LINING <br /> C.INTERIOR [D 5 GLASS LINING 8 UNLINED 95 UNKNOW O 99 OTHER <br /> LININGU-'n.Lj <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES— NO !Pf <br /> D.CORROSION ❑ 1 POLYETHYLENE WRAP 0 2 COATING Y% VINYL WRAP Q 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 0 5 CATHODIC PROTECTION 91 NONE III`"i�WW <br /> %///95 <br /> Ell O 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GR UNDOR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A tj PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A 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 S CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION AUTOMATIC LINE LEN DETECTOR 2 LINETIGHTNESSTESTING 0 MONB O W OTHER c.,.,�.,r <br /> V.TANK LEAK DETECTION UAWL -hO wwypQti e� Ter;j,l( " <br /> Q 1 VISUAL CHECK 2 INVENTORY RECONCILIATION O 3 VADOZE MONITORING O 4 AUTOMATIC TANK GAUGING O 5 GROUND WATER MONITORING <br /> TANK TESTING O 7 INTERSTITIAL MONITORING O 91 NONE 95 UNKNOWN 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO)DAY/YR) 2.ESTIMATED QUANTITY OF 3.WASTANK F ILLED WITH YES E 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 /> (PRINTED 8 SIGNATURE) <br /> LOCAL AGENCY USE ONLY THE STATELD.NUMBER IS COMPOSED OFTHE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK# <br /> STATE I.D.# ai = K i i i i ioui q "q3 <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE <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 /y 2 <br /> FORMS (12.91) �' ^ 1�� � FID v039r/� dJ�231/3/ <br /> Y <br />