BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA W c�" STATE WATER RESOURCES CONTROL BOARD ,;E' UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B ,Ys� 1 �_ Id; . COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY ❑ 1 ;NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TE ONE ITEM ❑ 2ERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE a TANK REMOVED DBA OR FACILITY NAME WRE TANK IS INSTALLED: Ale eUL Lµ I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN �� B. MANUFACTURED BY: A. OWNER'S TANK I.D.# C. DATE INSTALLED(MO/DAV/VEAR) D. TANK CAPACITY IN GALLONS: IL TANK CONTENTS IFA-113 MARKED,COMPLETE ITEM C. aREGULAR 3 DIESEL ❑ 6 AVIATIONGAS 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. 7PRODUCT ❑ UNLEADED 4 GASAHOL A. ❑ 7 METHANOL 2 PETROLEUM UM ❑ 80 EMPTY 1 ❑ 1DUNLEAIDEO ❑ 5 JET FUEL 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 ❑ 2 LEADED gg OTHER (DESCRIBE W ITEM D. BELOW) 0. IF(A.i)IS NOT MARKED, ENTER NAME OF SUBSTANCE STOPED C.A.S. III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALLTHAT APPLIES IN BOX D AND ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN A. TYPES. ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER SYSTEM 2 SINGLE WALL / BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP MATERIAL 5 CONCRETE (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER _ _ ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 10M. METHANOL? VES_ NO_ ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC D.CORROSION 91 NONE 95 UNKNOWN ❑ 99 OTHER PROTECTION F—] 5 CATHODIC PROTECTION E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IFUNDERGROUN ,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 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 p U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 MONITORING ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION /ATEYTE LAST USED(MO/DAV/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES 1.ESTIM ❑ NO� �(,(^,� SUBST CE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENH OF ERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME w,,/� ' (PRINTED a SIGNATURE) Y/'{/ tt K LOCAL AGENCY USE ONLY -THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# m M16-F-rT3d-5mi" PERMIT NUMBER PERMIT APPROVED BV/DATE PERM IT EXPIRATION DATE FORM 9 (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOR00348 fl5