BILLING - Laserfiche WebLink

Home Browse Search

At STATE OF CALIFORNIA J'e '' STATE WATER RESOURCES CONTROL BOARD y a, �'v UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B r� a COMPLETE A SEPARATE FORM FOR EACH ANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT le-1 CHANGE OF INFORMATION O 7 PERMANENTLY C ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 5 TEMPORARY TANK CLOSURE ❑ B TANK REMOVE / lZu / DBA OR FACILITY NAME WHERE TANK IS INSTALLED: , 3b7 y 54f—�G �----�" I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN - A. OWNERS TANK I.D.s oz B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYIYEAR) D. TANK CAPACITY IN GALLONS: SU+� 1I.TANK CO S IFA-1 IB MARKED,COMPLETE ITEM C. A. t MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ tAUN UNLEADED REGULAR 3 DIESEL ❑ e AVIATIONGAS a GASAHOL ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PROOUCT IDP IUM ❑ 7 METHANOL ❑ NLEADEO 5 JET FUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED W OTHER (DESCRIBE IN ITEM D. BELOW) 0. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.e: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOX D AND A. TYPE OF ❑ I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 UMINUM ❑ 8 100% METHANOL COMPATIBLE WIFRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING XY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 8 UNLINED ffkfs UNKNOWN ❑ 90 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 NYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE1)S UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CI AIFABOVEGROUNDORUIFUNOERGROUND,BOTHIFAPPLICABLE A. SYSTEM TYPE Ai SUCTKXN A U 2 PRESSURE A U 3 GRAVITY 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 C. MATERIAL AND A U / BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PMA U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 8 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 ❑ I AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ MDNIfORING ❑% OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 8 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 YES ❑ NO ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE IPRIKlE9 6 SIGNATU LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY» JURISDICTION 9 FACILITY 8 TANK s C Wts Z 3 STATE I.D.# U /JY 3 (oI I I 1 11 D ER PERMIT NUMBER PMIT APP VEQB TE PERMITEXPIRATION DATE FORM B (7 31) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS N FILE4-