BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA :� + STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. „ 1 ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE MARK ONLY �( 1 NEW PERMIT ❑ 3 RENEWAL PER ('I ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED / DBA OR FACILITY NAME WHERE TANK IS INSTALLED: LQ I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN S. MANUFACTURED By:: U h A OWNER'S TANK I.D.a D. TANK CAPACITY IN GALLONS: C. DATE INSTALLED(MO/DAY/YEAR) U n�. iEl 7CHFMICAtLPRODUCT AiF—1 IS MARKED,COMPLETE ITEM C. ❑ 1a REGU M UNLEADED 3 DIESEL ❑ 6 AVIATION GAS ' 4 OIL B. C. 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL PRODUCT ED 80 EMPTY ❑ 1c MIOGRADE UNLEA0E0 ❑ 5 JETFUEL ❑ 8 EM 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 98 OTHER(DE SCRIBE IN ITEM D.BELOW) C.A.S. D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B.AND C,AND ALL THAT APPLIES IN BOX AND E ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR UNER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN A. TYPE OF �r�yy1I ❑ ❑ 99 OTHER SYSTEM I^J 2 SINGLE WALL 4 SINGLE WALL IN A VAULT 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 8 100% METHANOL COMPATIBLE W/FRP MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 7 RUBBER LINED ❑ 8 UNLINED 95 UNKNOWN ❑ 99 OTHER LINING OR ❑ 5 GLASS LINING COATING IS UNING MATERIAL COMPATIBLE WITH 100% METHANOL] YES— NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION 97 NONE 95 UNKNOWN ❑ 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION ❑ SPILLCONTAINMENT INSTALLED(YEAR) OVE11 LI.—EN TION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,etc. DROP TUBE YES_ NO STRIKER PLATE YES__ NO_ DISPENSER CONTAINMENT YES NO_ 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 FLEXIBLE PIPING A U 99 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 A U i BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE C. MATERIAL AND A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP CORROSION A U 5 ALUMINUM A U 6 CONCRETE PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION p U 95 UNKNOWN ❑ A U 99 OTHER 99 OTHER 1 MEgVMGL ZINE LEAK ❑2 UNE MME ❑3 NWICISURWG INTERSTmAI ❑4 LEAK OEIECTOPEMMONIC E 5 sKumom PUMP D. LEAK DETECTION ❑ pETEOTOR TEsnND V.TANK LEAK DETECTION ❑ VADOZEMONITORING ❑ 4 GAUGING TANK ❑5 MON MONITOOUND RING ❑ 6 ANNUAL TANK INV❑ 1 VISUAL CHECK ❑ 2 FMANUAL IE ATIONORY 3 MONITORING TESTING ❑ 7 MONITORING NUOUINTERSTITIAL ❑ 8 SIR ❑ 9 WEEKLY MANUAL ❑10 MONTHLY TESTING TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 3.WAS TANK FILLED WITH YES ❑ NO 1.ESTIMATED DATE LAST USED(MOIDAY/YR) 2.ESTIMATED QUANTITY OF ,��L SUBSTANCE REMAINING IJE GALLONS INERT MATERIAL 7 RJURY,AND TO THE BEST OF MY KNOWLEDGE,EIS TRUE AND CORRECT THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PE TANK OWNER'S NAME (PRMTED 6 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW TANK# COUNN# JURISDICTION# FACILITY# STATE I.D.# m PERMIT NUMBER PERMIT APPROVED BYlDATE PERMIT EXPIRATION DATE MUST BE COMPLETED FOR THIS FORM MU SHOULD BE ACCOMPANIED BY AIPLO7 PIKE TOHIS FORM WITH THE LOCAL AGE CY IMPLEMENTING TTHEN FRM A UNLESS A CURRENT FORM A HAS BEEN FILED. wGROUND STORA STANK REGULATIONSNS.THIS FORM FORM B (6-95)