BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

• STATE OF CALIFORNIA • .�'°°" ` C� S�[-_t _ STATE WATER RESOURCES CONTROL BOARD =P c \` /( UNDERGROUND STORAGE TANK PERMIT APPLICATION •FORM B : ` o Y.�.'6. o' COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. �� owH,. MARK ONLY LD-:;Il 1 NEW PERMIT ❑ 3 RENEWAL PERMIT c•" ONE ITEM 2 INTERIM PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED , DBA OR FACILITY NAME WHERE TANK IS INSTALLED: G - I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A, OWNER'S TANK I.D.a B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAV/YEAR) D. TANK CAPACITY IN GALLONS; oJAIll I ILTANKCONTENTS IFA-i IS MARKED,COMPLETE ITEM C. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. 0 flEGULAR 2 PETROLEUM C. ❑ LEADED 3 DIESEL 6 AVIATION GAS ❑ 80 EMPTY 1 PRODUCT ❑ 1b PREMIUM 4 GASAHOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE UNLEADED ❑ 5 JET FUEL ❑ 7 METHANOL ❑ 2 LEADED ❑ 98 p7HER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.x: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C.AND ALL THAT APPLIES IN BOX D AND It A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER SYSTEM 2 SINGLE WALL ❑ ❑ 95 UNKNOWN 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ g POLYVINYL CHLORIDE ❑ 7 ALUMINUM (PrimaryTank) ❑ g BRONZE ❑ e 100% METHANOL COMPATIBLE W/FRP ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING C.INTERIOR ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑ 6 UNLINED �/ DES 95 UNKNOWN ❑ W OTHER IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL 7 _ YES_ NO --- D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 96 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE AIFABOVEGROUNDORUIFUNDERGROUND,BOTHIFAPPLICABLE A. SYSTEM TYPE A U 1 SUCTION p U 2 RESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A 1 SINGLE WALL A U-2 DOUBLE WALL A U 3 LINED TRENCH p U 96 UNKNOWN. p U 99 OTHER T C. MATERIAL AND AIqq (lBARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE( U 4 FIBERGLASS PIPE CORROSION A 5 ALUMINUM p U 8 CONCRETE PROTECTION A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESSA U 99 OTHER TESTING ❑ UONROgING 99 OTHE V.TANK LEAK DETECTION ❑ 1VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING E] 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING 8 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ gg OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED TE AST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF SUBSTANCE REMAINING3.WAS TANK FILLED WITH ❑ ❑ GALLONS INERT MATERIAL. YES NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNO APPLICANTS NAME WLEDGE, IS TRUE AND CORRECT (PRINTED 8 SIGNATURE( DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE I.DA 3LITY# (Z a3 i COUNTY# JURISDICTION# FACI —T TAN PERMIT NUMBER PERMIT APPROVED BV/DATE ILUI IL ILEI IL J � V PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORMA,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (12-91) /..//, IqFOR091M18116