BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

Y STATE OF CALIFORNIA `� y,'•$ STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B , a COMPLETE A SEPARATE FORM FO ACH TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT ❑ 2 RENEWAL PERMIT 6 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑ 6 TANK REMOVED DBAOR FACILITY NAME WHERE TANK IS INSTALLED: 167 E;112 1111�9a-1 I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# 07, B. MANUFACTURED BY: 4l Al C. DATE INSTALLED(MO/DAY/YEAR) /%, D.TANK CAPACITY IN GALLONS: II.TANK TENTS IFA-11S MARKED,COMPLETE ITEM C. 1a REGULAR 3 DIESEL ❑ 6 AVIATIONGAS A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C• UNLEADED 4 GASAHOL ❑ 2 PETROLEUM BO EMPTY 1 PRODUCT ❑ 1b PREMIUM ❑ 7 METHANOL ❑ UNLEADED ❑ 5 JETFUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED{., ❑ 99 OTHER (DESCRIBE IN ITEM D. BELO" O. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED !k S (/1.�'/R-� 7 C.A.S.# III. TANK CONSTRUCT N MARK ONE ITEM ONLY IN BOXESA.S.ANDC,AND ALLTHAT APPLIES INBOX D AND [:IBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN A. TYPE OF 99 OTHER SYSTEM 2 INGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM E] 8 100% METHANOL COMPATIBLE W/FRP MATERIAL ❑ (PllmuyTWt) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 96 UNKNOWN E] W OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOW ❑ 99 OTHER LINING ,�,� IS LINING MATERIAL COMPATIBLE WITH 100% METHANOLS YES_ NO w'4� D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑�MYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE OV l/95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE AIFABOVEGR OR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A RESSURE A U 3 GRAVITY A U 99 OTHER 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 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 S ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DEFECTION 1 AUTOMAT IC LINE LEAK DETECTOR Q2 LINE TIGHTNESS ..TESTING ❑Ill E]99 OTHER Q�� V.TANK LEAK DETECTION UA &#G rrIll � - -' ��&'Wolp VVV❑�9 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANKGAUGING ❑ 5 GROUND WATER MONITORING TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 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 IPRDITED 4$IGK4TIRQ LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# RT11 EI= X y 3 ET I I 1101X 9� g PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT 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) 1 � � F0 Do34yq3 31I� q ORMS-146 ...A �