BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

i.w.re� STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD " �'; 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 EDII PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.I S. MANUFACTURED By.- C. Y:C. DATE INSTALLED(MOIDAV/YEAR) O D. TANK CAPACITY IN GALLONS: L I II.TANK CONTENTS IF A-1 1S MARKED.COMPLETE ITEM C. A ;S,1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. 1a REGUWi UNLEAD® 3 DIESEL S AVIATION GAS ❑ 2 PETROLEUM ❑ BO EMPTY 1 PRODUCT ib PREMMN UNLEADED 4 GASAHOL ❑ T METHANOL ❑ ❑ 85 UNIWOWN (❑ 2 WASTE ❑ 1C NIO(iR1DE UNLEADED O 5 JET FUEL ❑ 9 MBS 3 CHEMICAL PRODUCT 2 LEADED o ❑ BB OTHER(DESCRIBEWffFN D.BELOW) D. IF(Al)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.I: 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 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC - MATERIAL ❑ 5 CONCRETE ❑ 9 POLYVINYL CHLORIDE ❑ T ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (Pk—Y TMq ❑ B BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ALKYD LINING ❑ 3 EPDXY UNING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING Tws UNLINED ❑ 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,fiM. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES_ NO STRIKER PLATE YES_ NO_ DISPENSER CONTAINMENT YES_ 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 U 1 SINGLE WALL A U 2 DOUBLE WALL 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) U> FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U S CONCRETE A U T STEEL WIOOATING A V B 10D% METHANOL COMPATIBLEWIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTIONT UNE I 1 nEcxrMcu FAK ME KYRI&BE 3 cdlrNuous alreRsrm4L 4 EIECiBOXIC UIE 5 A9I9 =PUMP ❑ ❑ 9ETELfd1 ❑2 TESIPlG MONIORNB ❑ lLV(OEIECfOR ❑ BiUI00WX 99 OTHER V.TANK LEAK DETECTION 1 VISUAL CHECK ❑ 2 MANUALILIATIONORY [D3 VADOITZE ORING E::] 4 GAUGINGC TANK ❑ 5 GROUND MONITOWATER [:]6 ANNUNGTANK RECONCT MONITORING INTERSTITIAL ❑ B SIR ❑ 9 WEEKLY MANVAL ❑ 10 MONTHLY TANK ❑ 95 UNKNOWN 99= TANK GAUGING TESTING ❑ VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE N-PLACE) 1.ESTIMATED DATE LAST USED(MOIDAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME O= SIfYUTUREI � '/ LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THEFOURN MBB`ERS BELOW COUNTY M JURISDICTION N FACILITY k TANK M STATE I.D.# m 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. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLAN. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (&95)