BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

4Uun � STATE OF CALIFORNIA \� �• ""'�'t, STATE WATER RESOURCES CONTROL BOARD s UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B "� : o Y/ � ID �1 ' COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. �"'"°" MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED a r DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 33o Lam- V 4AI LoA7-- I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# B. MANUFACTURED BY: v, C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: ID I) 11.TANKCONTENTS IFA-11S MARKED,COMPLETE ITEM C. p, 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1-UNLEADED REGULAR 3 DIESEL 116 AVIATION GAS ❑ 2 PETROLEUM ❑ m EMPTY C. 1 PRODUCT 1b PREMIUM E:JGASAHOL 7 METHANOL 0 UNLEADED ❑ 5 JETFUEL ❑ ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#1: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOX D AND E ^7p (G CnAITE Tr Ca,k, • 23.�C> A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ��-y"'D5 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) U a6 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PdmwyTmk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? NYE _ NO D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING 3VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION O 5 CATHODIC PROTECTION L_] 91 NONE 95 UNKNOWN O 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A- SYSTEM TYPE SUCTION A U 2 PRESSURE 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 Adr-A 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 STEEL W/COATING A U 8 10O% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A 96 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR Q 2 LINE TIGHTNESS TESTING Q 3 99 OTHER MONROflING ❑ V.TANK LEAK DETECTION 5Q7,1 UAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMgTIC TANK GAUGING 5 GROUND WATER MONITORIK TESTING O 7 INTERSTITIAL MONITORING O 91 NONE O 95 UNKNOWN O 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TA NK FILLED WITH SUBSTANCE REMAINING GALLONS INERTMATERIAL7 YES ❑ NO j THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE IPRMTED 6 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION It FACILITY# TANK# STATE I.D.# I I © �,-r PERMITNUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE t1�7j THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN F FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATION .j/3/ FORMS (12-91) - &96