BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

SPATE OFCAU FORMA `at STATE WATER RESOURCES CONTROL BOARD 3A UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLglINONE REM r-12 INTERIM PERMIT L_] 4 AMENDED PERMIT [:] S TEMPORARY TANK CLOSURE O S TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 6 lAU a G I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.# v 4- B. MANUFACTURED BY: C. DATE INSTALLED(MO(DAY/YEAR) D. TANK CAPACITY IN GALLONS: ILTANKCO ENTS IFA-11S MARKED,COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ IaREGULAR ED 3 DIESEL ❑ 6 AVIATK)NGAS ❑ 2 PETROLEUM E::] SO EMPTY 1 PROIXICT ❑ 1b PREMIUM B 4 GASAHOL ❑ 7 METHANOL �NLEADED ❑ 5 JETFUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN O 2 WASTE 2 LEADED O 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.0: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES B.AND C.AND ALL THATAPPLIES IN BOX D A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL 2 STAINLESS STEEL 0 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 MINUM ❑ 6 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 96 UN OWN O 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LININGEPDXY LINING E:] 4 PHENOLIC LINING C.INTERIOR F-15 GLASS LINING E::] 6 UNLINED 95 UNKNOWN 99 OTHER LINING ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— /NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP E::] 2 COATING NYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 90 OTHER 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 U GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH 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 5 ALUMINUM A U 6 CONCRETE A U 7 STEELICOATING A U 6 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 NTERTfTIAL OTHER MOW V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING n 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE �I��, 96 UNKNOWN O 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIM.;EDyMfED(MO/DAV/VR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAININGy GALLONS INERTMATERIAL7 YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME DATE IPNm 0a SIGNATJW LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# ® = olowl6 El==a4 17- PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE C�- 7 7a FORM B(490) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED.