BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

WEE STATE OF CALIFORNIA �` STATE WATER RESOURCES CONTROL BOARD sy EE.� " UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B "mom ~^ w, I COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATIONn 7 PERMANENTLY CLOSED ON SITE ONE REM F72 INTERIM PERMIT O4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 6d 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Firoo s' I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNERS TANK I.D.# WL I B. MANUFACTURED BY: CUE C. DATE INSTALLED(MODAYNEAR) D. TANK CAPACITY IN GALLONS: 11.TANK CONTENTS IF A-1 IS MARKED.COMPLETE ITEM C. A N 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. to REGUWI UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS F72 PETROLEUM ❑ 80 EMPTY E-] 1 PRODUCT tb PREMIUM UNLEADED O 4 GASAHOL a 7 METHANOL ❑ 1C MIDGRADE UNLEADED O 5 JET FUEL ❑ 8 MSS O 3 CHEMICAL PRODUCT O 95 UNKNOWN ❑ 2 WASTE O 2 LEADED ❑ 99 OTHER(DESCRIBE IN REM D.BELOW) D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.# III. 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 O 5 INTERNAL BUDDER SYSTEM ❑ 95 UNKNOWN SYSTEM I� 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK I^I 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS O 4 STEEL CLAD N FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE O 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 10D% METHANOL COMPATIBLE W/FRP (PrimaryTank) Q 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING 5;d-6 UNUNED O 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ® 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,9IC. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES_ NO_ STRIKER PLATE VES_ NO_ DISPENSER CONTAINMENT VES 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 U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A ip 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 UNED TRENCH A U 95 UNKNOWN A U 98 OTHER C. MATERIAL AND A IV 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 6 CONCRETE A U 7 STEEL NCOATING A U 8 100% METHANOL COMPATIBLENRiP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑1 MEGMNGL UNE LEAK ❑2 Uri TDH1 W ❑3 cartNuaus NTE95T911L ❑4 EURmKWC UNE ❑s AROLMBC PmP ❑ 99 MER EET m TESTea Ma4raRNG IFAX oEDEcroR 9NIOOVM V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL INVENTORY r7UATON 3 MONITORING Z LNG ❑ 4 A�UUOMAC'TIC TANK O 5 MONITORING ❑6 ANNUAL TESTING RECONC❑ 7 CCOOMTNNURODUS ING INTERSTITIAL O B SIR ❑ 9 TRK LY M NGAL ❑10 MONTHLY TANK O 95 UNKNOWN O 99 OTHER STIN VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IWPLACE) 1.ESTID{DATE LAST USED(MOIDAWYR) ZESTIMATED MATEC RE�NGF �T 3.WA STANK FILLED WffH VES ❑ NOLAA � IL S GALLONS INERT AUTERIAL 7 THIS FORM HAS BEEN COMPLETED UNDER PE OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER' NAM ��/ A/IL( 1t e.�' 1,D' / p e. DATE (PRMTEp69GNAT q_!SUC 1_ ""KA.L L� •1L `/lo/VA'��vv` !'r 1 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK M STATE I.D.# m = 0 PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICE*ION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT P RLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THF �RGROUND f.J+J S))) /�&� `�,6 / tTORAGE TANK REGULATIONS � FORM B (6-95) �� L.