Laserfiche WebLink
STATE OF CALIFORNIA e` <br /> V STATE WATER RESOURCES CONTROL BOARD <br /> ,sem ✓;. <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B f <br /> n. . <br /> ' , " COM!�ETE A SEPARATE FORM FOR EACH TANK SYSTEMA <br /> MARK ONLY I NEW PERMIT 3 RENEWAL PERMIT U 5 CHANGE OF '�NFORMATICN J T PERMANENTLY CLOSED <br /> 2 INTERIM PERMIT ❑ A AMENDED PERMIT s TEMPORARY TANK CLOSURE i 8 TANK REMOVED 1, <br /> ONE ITEM _ -' <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.O.a I L 0. MANUFACTURED BY: V K <br /> C. DATE INSTALL`cD(MNDAYHEAR) 3 0. TANK CAPACITY IN GALLONS: 6� 000 <br /> ILTANK C ENTS FA-IISMARKED.00MPLEl RENC <br /> t a ] DIESEL a AVIATION GAS <br /> MOTOR VEHICLE FUEL A OIL 4 C. UNLEADED <br /> A a GASNIOL <br /> 2 PETROLEUM U 90 EMPTY C PgOOUCT I ;� IEPgEMIUM !J 7 METHANOL <br /> UNLEADED 5 JET FUEL <br /> 3 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE I IJ 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> 0, IF(At)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED 9 C.A.S.0: <br /> A �,' <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES S.AND C.AND ALL THAT APPLIES IN SOX D Z�' � (-) <br /> DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LIVER u 35 UNKNOWN <br /> A. TYPE OF -� -I 99 OTHER <br /> SYSTEM IJ 2 SINGLE WALL ❑ a SECONDARY CONTAINMENT VAULTED TANK) <br /> IJ t 9ARE STEEL 2 STAINLESS STEEL K 3 �,BERGLASS A STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC <br /> B. TANK 5 CONCRETE e POLYVINYL CHLORIDE I 7 ALUMINUM 8 100% METHANOL COMPATIBLE WIFRP <br /> MATERIAL <br /> (Primary Tank) 9 BRONZE I� 10 GALVANOED STEEL 1 95 JNINOWN J W OTHER <br /> —'i I RUBBER LINEDPy'�YD LINING �J— 3 EPDXY LININGI� s PHENOLIC LINING <br /> C.INTERIOR r^ 5 GLASS UNNG a UNLINED 9S UNKNGWN 9P OTHER <br /> LINING <br /> IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL.? YES_ No <br /> .J I POLYETHYLENE WRAP J 2 COATING J 3 VINYL WRAP A FIBERGLASS REINFORCED PLASTIC <br /> 0.CORROSION <br /> PROTECTION '= 5 CATHODIC PROTECTION 1= 91 'NONE as UNKNOWN —7 n OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U I SINGLE WALL A U 2 DOUBLE WALL LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) PIRERGLASS PIPE <br /> CORROSION A U S KUNNUM A U S CONCRETE A U 7 STEEL V COATING A U 9 100% METHANOL COMPATIBLE WFRP <br /> PROTECTION AB UT 9 GALVANIZED STEEL A U 10 CATHODICPgOTECTION A U 9S UNKNOWN A U N OTHER <br /> D. LEAK DETE = <br /> CTION I AUTOMATIC UNE LEAK DE iECTOA r INETIGHTNESSTESnNG _ O MONRORWG OTHER <br /> V.TANK LEAK DETECTION <br /> X-7 VISUAL CHECK I7 2 INVENTORY RECONCILIATION = 3 VAPOR MONITORING= a AUTOMATIC TANK GAUGING 5 GROUND WATER MONITORING <br /> 18 TANK TESTING = 7 INTERSTTTIALMONITORING ❑ 91 NONE 77 95 UNKNOWN 1� 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> I.ESTIMATED DATE LAST USED(MOIOAYNR) 2.ESTIMATED GUANTRY OF I S WAS TANK FRIED WITH <br /> YES <br /> SUBSTANCE REMAINING GALLONS INERTMATERIAL? <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY XNOWLEDGE; IS TRUE AND CORRECT <br /> APPLICANTS NAME DATE <br /> IPIaNTE9 a SMNATNRfl <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY;* JURISDICTION# FACILITY TANK s <br /> STATE I.D.# T I 1 / 1 <br /> 6' <br /> PERMIT NUMBER PERMIT APPROVED BYIDATE i PERMIT EXPIRATION DATE 1�2j <br /> FORM 8 (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPUCATION-FORM A.UNLESS A CURRENT FORM B'EEM FlIID. <br /> kF �,IyC P011�a9M <br />