BILLING - Laserfiche WebLink

Home Browse Search

VIAL STATE OF CALIFORNIA .L. ^. STATE WATER RESOURCES CONTROL BOARDMAY Q 4 1A i ,. •• 9 UNDERGROUND STORAGE TANK PERMIT APPLICATION FORM B AL =° 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 ❑ 66,TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILRY NAME WHERE TANK IS INSTALLED. I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.N B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) e'f_I D. TANK CAPACITY IN GALLONS: �. II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. p ❑ 1 MOTOR VEHICLE FUEL ❑ 4OIL B. C. ❑ 1S REGULAR UNLEADED O 3 DIESEL ❑ 6 AVIATION GAS �2 PETROLEUM ❑ BO EMPTY 1 PRODUCT ❑ 1b PREMNM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ Ic MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED 99 OTHER(DESCRIBE IN REMD.BELOM D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED CL S.M III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,ND ALL THAT APPLIES IN BOX D AND E A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR UNER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 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 ❑ 8 100% METHANOL COMPATIBLE W/FRP (PNmery TMlk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER UNED �❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING yJCLB UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLEWITH100% METHANOL? YES_ NO& D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION,?�r_91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,MC. SPILLCONTAINMENT INSTALLED EAR) OVERFILL PREVENT) N EQUIPMENT INSTALLED(YEAR) 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 U SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A 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 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 AECKWIG UNE LEAK [:�]2 UNE TIGKTNESS E:]3 CONRNUWS IMERST & ❑4 ELECTRONIC NR LINE 5 AUfO1MRC WMP ❑ 99 OTHE 9ELECToR TESTING MCNTmm LTAN OEIECSMPDOWN V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCILIATION ORV ❑ 3 MONITORING ❑ 4 GAUGNGAUTOMATIC TANK 5 MONTORINGIOUND WATER ❑ 6 TNESTINGTANK ❑ 7 MONITORING CONTINUOUSINTERSTITIAL ❑ 8 SIR ❑ 9 TANK LY MANUAL ❑10 MONTHLY TANKNO 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) { 1. ATED DTE TUBED(Mj1 Y 2.ESTIMATED SUBSTANCE REMAININGAGALLONS 3 WpINERT TANK FILLERIA 7M yES ❑ NO �L THIS FORM HAS BEENCOMPLETEDUNDER PENALTY OF PERJUTHE F NO T D CORRECT' TANK OWNER'S Nry1G/' DAT LOCAL(PRINTED B SIGNATURE) ` ` l LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS C POSE OF E FOUR MBERS COUNTY# JURISDICTION N FACILITYN TANK# 4) 1 STATE 11 LD:# 5 0 � o/ S o Z PERMIT NUMBER PEflM1T APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FORM C MUST BE COMPLETED OR INSTALLA ONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLAN. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (6-95) 0 0