BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

n STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD u �, e > 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 ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED'. DBAOR FACILITY NAME WHERE TANK IS INSTALLED: )d ER CAEOL.F('*IDN 02 4a1A'-v Rct Lc(th,-c Ca. I TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I. D. # 1 B. MANUFACTURED BY: /'/ pry EAN &)L , q C DATE INSTALLED(MOIDAV/YEAR) �i - S -Q D. TANK CAPACITY IN GALLONS: ,20100o R TAuv PnNITCKITC ... ueI l .'.r. A ® 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. © le REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 1b PREMIUM UNLEADED r❑ 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ 80 EMPTY Z) I PRODUCT ❑ Ic MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 6 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 -LEADED ❑ 99 OTHER(DESCRIBE IN REM D. BELOM D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. 4: III TANK rnNSTRurnON MARK ONE ITEM ONLY IN BOXES A B. AND Q AND ALL THAT APPLIES IN BOX D AND E N DIDIMC HdNnCNIATlnM PIRCIC A 10 ARnVP r.RnUNn OR U IF UNDERGROUND. BOTH IF APPLICABLE A. SYSTEM TYPE ® 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN A. TYPE OF SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER I SINGLE W4 ❑ I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ® 8 100% METHANOL COMPATIBLE W/FRP (Primly Twlo ❑ 9 BRONZE Cl 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER UNED O 2 ALKYD UNING O 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING OR ❑ 5 GLASS LINING © 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH IDD% METHANOL? YES ✓ NO— D. EXTERIOR ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ® 4 FIBERGLASS REINFORCED PLASTIC CORROSION ❑ CATHODICPROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER PROTECTION 5 SPILL CONTAINMENT INISTALLED (YEAR) OVERFILL fPREVENTON EQUIPMENT INSTALLED (YEAR) DISPENSER CONTAINMENT VES NO_ E. SPILL AND OVERFILL, fisc. DROP TUBE YES_✓✓ NO,_ STRIKERPLATE YES r NO_ N DIDIMC HdNnCNIATlnM PIRCIC A 10 ARnVP r.RnUNn 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 I SINGLE W4 Ag 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND CORROSION PROTECTION A U A U A U 1 BARE STEEL 5 ALUMINUM 9 GALVANIZED STEEL A U 2 STAINLESS STEEL A U A U 6 CONCRETE A U A U 10 CATHODIC PROTECTION 3 POLYVINYL CHLORIDE (PVC)A U 4 FIBERGLASS PIPE 7 STEEL W/COATING AO8 100% METHANOL COMPATIBLE W/FRP A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ®1 LAcxNmrAL uxE LMK ❑ pETECfOR 2 UNE Tr4ON ' ®3 Cm6Nuaus IxrERsnnAL ❑ , ELECTRONIC UNE ® TEsINm NCNTOX LEAN OEIEC 5 MOM= WIP ❑ 99 OTHER sHmT00WN V TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL INVENTORY ❑ 3 VADOZE M N RI 4 GAUG NG AUTOMATIC TANK ❑ 5 GROUND MONITORING TSR ❑ S ANNUALTESTING 7 Sl MONTORING INTERSTITIAL ❑ 8 SIR ❑ 9 WEEKLY MANUAL ❑ 10 TON HLy TANK ❑ 95 UNKNOWN ❑ 89 OTHER VI. TANK CLOSURE INFORMATION (PERMANENT CLOSURE IN-PLACE) 1. ESTIMATED DATE LAST USED (MO/DAYNR) 2. ESTIMATED OUANTITY OF 3. WAS TANK RULED WITH YES E:] NO ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS &EN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNERS NAME y//� -/n)T D�AgTE pp (PRWTFDm61GNAlUREj 4 1 _ 1 /< LOCAL AGENCY USE ONLY THE STATE 1.6. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # 00%05'J TANK # 00 STATE I.D.9 m FTFI I I I 18 1 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APP QN- FORM A, UNLESS A CURRENT FORMA HAS BEEN FILED. F" MUST BE COMPLETED FOR INSTALLATIONS. THIS FUHM SHOULD BE ACCOMPANIED BYAPLOTP '.ILE THIS FORM WITH THE LOCAL AGENCY IMPLE(M�F��T�LNfG�T�H .B GROUND STORAGE TANK REGULATIONS FORM B (6-95)