BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CAUFORNA o^ STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION^ FORM B `e I Da 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 ❑ A AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS-SPECIFY IF UNKNOWN a76 A OWNERS TANK L D.a S. MANUFACTURED BY: C. DATE INSTALLED(MOIDAYIYEAR) GJ J D. TANK CAPACITY IN GALLONS: 6 ILTANKC ENTS IFA-11SMARKED.COMPLETE REMC. A. I MOTOR VEHICLE FUEL ❑ a OIL S, C ❑ I&REGULARD DIESEL ❑ e AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT 1D PgEMIUM a GASOHOL 7 METHANOL ❑ 3 CHEMICAL PRODUCT E] % UNKNOWN ❑ 2 WASTE ❑ 2 UNEAOED D 5 JET FUEL 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)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 THATAPPLIES IN BOX A. TYPE OF ❑ I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ a SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ a STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANISED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR LINING ❑ 5 GLASS LINING ❑ 8 UNLINED ❑ 93 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO— D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ a FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION a 91 NONE ❑% UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFA80VEGRIX)NDOR U IF UNOERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U I SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U % UNKNOWN A U % OTHER C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U a FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 8 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANREO STEEL A U 10 CATHODIC PROTECTION A U % UN104OWN A U 99 OTHER D. LEAK DETECTION C] I AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING 3 WMONROR 4 aML ❑ ❑ 9 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ a AUTOMATIC TANK GAUGING ❑ 5 G=WAMRMCNITOIIING8 TANK TESTING ❑ 7 INTERSTITIALMONITORING ❑ 91 NONE ❑ % UNKNOWN ❑ 99 VI.TANK CLOSURE INFORMATION 1,ESTIMATED DATE LAST USED(MO DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING 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 IPRWTan a sW WTIRET DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# 3F% ET, PERMIT NUMBER PERMIT APPROVED BriDATE PERMIT EXPIRATION DATE O� FORM B (&%) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. PoNaCOaBAt