BILLING - Laserfiche WebLink

Home Browse Search

.r 4 STATE OF CALIFORNIA b + STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B °e . I COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 0 TANK REMOVED IDEA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN I B. MANUFACTURED BY: UKL A OWNER'S TANK I.D.# i U 1• TANK CAPACITY IN GALLONS: C. DATE INSTALLED(MO/DAV/YEAR) K,- II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ la REGULAR UNLEADED 3 DIESEL ❑ 6 AVIATION GAS NLEADED A. ❑ i PRODUCT O Ic MIlb REMIUM UUNLEADED 5 GET FUELE36 M685 �2 PETROLEUM BO EMPTY DGRADE Lam} ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBEIN TEM D.BELO ❑ 3 CHEMICAL PRODUCT W) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.p III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.0,AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDESYSTEIM ❑ 95 UNKNOWN I�-�{ ❑ 4 SINGLE WALL IN A VAULT ❑ 89 OTHER SYSTEM IL�S�I 2 SINGLE WALL B. TANK Lal 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/ S REINFORCED PLASTIC MATERIAL' ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE7 ALUMINUM ❑ 6 100% METHANOBLE WlFRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY UNING E] 4 PHENOLIC LINING C.INTERIOR 8 UNLINED ® 95 UNKNOWN ❑ 99 OTHER LINING OR E] 5 GLASS LINING ❑ COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIQ CORROSION 9S.Ut PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE -� ❑ UNKNOWN 99 OTHER SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,BIC. DROPTUBE YES_ NO__ STRIKER PLATE VES_ NO DISPENSER CONTAINMENT VESNO _ URNIL IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND 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 UEXIBLEPIPING A U 89 OTHER B. CONSTRUCTION A 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 WlCOATING A U 6 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER 1 MEOXONICAL UNE IFAN 2 LINE TIGHTNESS ❑3 CONRNUWS IWERST L ❑1 ESC OETECTOF ❑5 SNNW PUMP ❑ 99 OTHER D. LEAK DETECTION ❑ pETEGTGR ❑ TESTING MOMTGRING V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RMANUAL ECONCILIATION MONITORING ❑ 3 MO IT�Oyy.�RING OZE ❑ 4 GAUGING MONITORING TANK ❑ 5 GROUND MONTORINGiE` `�'6 TESTINGANNUAL ❑ 7 MONITORINGINTERSTITIAL ❑ 6 SIR ,�,9=AENEKK/Gi1 GINGAL ❑10 MONTHLTESTINGY TANK ❑ 95 UNKNOWN u 99 OTHER l /U C VI.TANK CLOSURE INFORMATION(PERMANEIl CLOSURE IN-PLACE) J 2.ESTIMATED QUANTITY OF I,# 3.WAS TANK FILLED WITH YES E:l NO 1.ESTIMATED DATE LAST USED(MO/DAYlYH) SUBSTANCE REMAINING , ✓�w GALLONS INERT MATERIAL? l , 11 vi� THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGlz;1§t,tUE AND CORREC TANK OWNER'S NAME DATE pL-� la7 I (PRINTEDd SIGNATURE) � Q� LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY#Q 73I TANK#x/ STATE I.D:# m 0 1 3 0 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION UATE ,/ THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPUC=N•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. POW BE COMPLETED FOR INSTA TIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLWE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE GROUND STORAGE TANK REGULATIONS FORME (6-95)