BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

^ezo�P p co STATE OFCAIFORMA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B "tee COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. `"•�^"'' MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE �ANK REMOVED OBAOR FACILITY NAME WHERE TANK IS INSTALLED: 2 Lz)o J c I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.• 3 B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: Oco II.TANK CONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. O. ❑ 1aREGULAR UNLEADED DIESEL ❑ 6 AVIA ION GAS ❑ 2 PETROLEUMUM 4 GASAHOL 3 CHEMICALPRODUCT ❑ EMPTY 2-1—PRODUCT ❑ 1bUN UNLEADED ❑ 5 JET FUEL ❑ 7 METHANOL ❑ ❑ 95 UNKNOWN ❑ 2 WASTE O 2 LEADED ❑ ❑ 99 OTHER (DESCRIBE IN REM . BELOW) D. IF(A.i)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.a: III. TANK CONSTRUCTION MARKONE ITEM ONLY IN BOXES A,BAND C.ANDALLTHATAPPLIES INBOXD A. TYPE OF ❑ i BLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED)PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 100% METHANOL COMPATIBLE W/FRP (Primary Ta6k) ❑ g BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED [—] 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.IN ININGR ❑ 5 GLASS LINING ❑ 6 UNLINED E:��MOWN ❑ ea OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_1 POLYETHYLENE WRAP NO— D.CORROSION 2 COATING ❑ WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC ❑ PROTECTION [-] 5 CATHODIC PROTECTION ❑ 91 NONE 5 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 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)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 6 100% METHANOL COMPATIBL W/FFP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U09NKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR LINE TIGHTNESS TESTING3IMON01 ASI I IU1 gg OTHER V.TANK LEAK DETECTION NITORNG ❑ ❑ 1 V CHECK - r2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MON TORING 6 TANK TESTING �❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH 3.. C( SUBSTANCE REMAINING © GALLONS INE RT MATERIAL? YES ❑ N THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME (PRINTED a SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE LDACOUNTY# JURISDICTION# Z �FACILRYi� TAS—LF—��J�A.JV E� PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE S- FORM 8 (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. F &R4 i