Laserfiche WebLink
• STATE OF CALIFORNIA • r°'�r"" <br />s cP <br />STATE WATER RESOURCES CONTROL BOARD`S c <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br />COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. " <br />MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE <br />ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED <br />DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Z y0O Giv _ GOLJ,T �4✓f. S'7' <br />i. v�savmr nwr I.UMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br />A OWNER'S TANK I. D. Y v, B. MANUFACTURED BY: <br />C. DATE INSTALLED(MC/DAYNEAR) 9 %/ D. TANK CAPACITY IN GALLONS: <br />u. I nlvIN Mull1 Ell 1.7 IFA -1 IS MARKED. COMPLETE ITEM C. <br />A 6!1OTOR VEHICLE FUEL ❑ 4 OIL <br />B.[[[TTT���� <br />C. la REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS <br />❑ 2 PETROLEUM ❑ 80 EMPTY <br />PRODUCT <br />PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL <br />❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN <br />❑ 2 WASTE <br />❑ 1c MIDGRADE UNLEADED ❑ 5 JETFUEL ❑ 8 M85 <br />1 BARE STEEL <br />❑ 2 STAINLESS STEEL <br />❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br />D. IF (AA) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. M: <br />nl. In"M I.VPIJInULs IIVI`4 MARK ONE ITEM ONLY IN BOXES A. B. AND C. AMO All THAT APPIIPR IM Rnv n e., <br />A. TYPE OF <br />I1� DOUBLE WALL <br />❑ 3 SINGLE WALL WITH EXTERIOR LINER <br />E]5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN <br />SYSTEM <br />Ip❑Ip�I <br />E nos SINGLE WALL <br />❑ 4 SINGLE WALL IN A VAULT <br />❑ 99 OTHER <br />B. TANK <br />1 BARE STEEL <br />❑ 2 STAINLESS STEEL <br />❑ 3 FIBERGLASS <br />❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC <br />MATERIAL <br />❑ 5 CONCRETE <br />❑ 6 POLYVINYL CHLORIDE <br />❑ 7 ALUMINUM <br />❑ 6 100% METHANOL COMPATIBLENFRP <br />(Primary Tank) <br />❑ 9 BRONZE <br />❑ 10 GALVANIZED STEEL <br />❑ 95 UNKNOWN <br />❑ 99 OTHER <br />C. INTERIOR <br />❑ 1 RUBBER LINED <br />❑ 2 ALKYD LINING <br />❑ 3 EPDXY LINING <br />❑ 4 PHENOLIC LINING <br />LINING OR <br />❑ 5 GLASS LINING <br />�j 6 UNLINED <br />❑ 95 UNKNOWN <br />❑ 99 OTHER <br />COATING <br />IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? <br />YES_ NO— <br />D. EXTERIOR <br />CORROSION <br />❑ 1 POLYETHYLENE WRAP2 <br />❑ COATING <br />❑ 3 VINYL WRAP <br />❑ 4 FIBERGLASS REINFORCED PLASTIC <br />PROTECTION <br />5 CATHODIC PROTECTION ❑ 91 NONE <br />95 UNKNOWN <br />❑ 99 OTHER <br />E. SPILL AND OVERFILL, BSC. SPILL CONTAINMENT <br />INSTALLED (YEAR) <br />OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) <br />DROP TUBE YES_ <br />NO_ STRIKER PLATE <br />YES_ NO <br />DISPENSER CONTAINMENT YES NO_ <br />IV. riFiNG IIYrUHMA I ION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND. RnTH IP APPI IrLRI9 <br />A. SYSTEM TYPE <br />A U 1 SUCTION <br />A tV2 PRESSURE A U <br />3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER <br />B. CONSTRUCTION <br />AjV1 SINGLE WALL <br />A U 2 DOUBLE WALL A U <br />3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br />C. MATERIAL AND <br />CORROSION <br />PROTECTION <br />A U 1 BARE STEEL <br />A U 5 ALUMINUM <br />A U 9 GALVANIZED STEEL <br />A U 2 STAINLESS STEEL A U <br />A U 8 CONCRETE A U <br />A U 10 CATHODIC PROTECTIONAoY <br />3 POLYVINYL CHLORIDE (PVC)A U 4 FIBERGLASS PIPE <br />7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP <br />95 UNKNOWN p U 99 OTHER <br />D. LEAK DETECTION <br />❑ 1 ME—M LINE LENT( ❑ <br />OEIECTOR <br />2 UNE TKa WM E] 3 CONRNUWS WTERSTIMI4 BECTROMC UNE 5 AuraunC PUMP <br />TESTING MONTMING ❑ 1&1K DETECTOR ❑ SHUTDOWN ❑ 99 OTHER <br />V. IMIYq LCAA UCICL.IIUIY <br />❑ 1 VISUAL CHECK Lpl 2 RECONCILATIONANUAL INVENTORY ❑ 3 MONIITORING OZE ❑ 4 GAUGING MONITORING <br />TANK ❑ 5 GROUND MONTORINGWATER ❑ e TESTINGTANK <br />❑ T <br />MONITORING INTERSTITIAL IL+�D B SIR ❑ 9 WEEKLY MANUAL ❑ 10 MONTHLY TANK ❑ 95 UNKNOWN 99 OTHER <br />TANK GAUGING TESTING ❑ <br />rl. Inlvn VLVJVI3C IIYPUMMA I IUN (PERMANENT CLOSURE IN-PLACE) <br />1. ESTIMATED DATE LAST USED (MO/DAYNR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES ❑ NO ❑ <br />SUBSTANCE REMAINING GALLONS INERTMATERIALT <br />THL <br />rumor r1AJ LittN UUMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORF <br />TANK OWNER'S NAME DATE <br />(PRINTED a SIGNATURE) <br />FCT <br />LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br />COUNTY # JURISDICTION # FACILITY X TANK # <br />STATE LD:#5 `8% �9G <br />PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE q / <br />d N G <br />THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION- FORM A, UNLESS A CURRENT FORMA HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALL TIONS. THIS FORM <br />SHOULD BE ACCOMPANIED BY A PLOT PLAN. RLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE ROUND STORAGE TANK REGULATIONS <br />FORMS (6-95) 0 <br />FOR00349-BT <br />