BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CAUFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B > �, 1a+ COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. \ ❑ ❑ 7 PERMANENTLY CLOS ON SITE NEW PERMIT 3 RENEWAL PERMIT MARK ONLY 1 ❑ 5 CHANGE OF INFORMATION \I ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN 8. MANUFACTURED BV: `� A OWNER'S TANK 1.D.♦ / N D. TANK CAPACITY IN GALLONS: �S� +� J C. DATE INSTALLED(MOA7AY/YEAR) /l II.TANK C NTENTS IF A-1 IS MARKED,COMPLETE ITEM C. fi AVIATION GAS to REGULAR UNLEADE:- A 3 DIESEL ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL 9. C ❑ b PREMIUM UNLEADE4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT ❑ 1c M10GRADE UNLEAD5 JET FUEL ❑ 8 M85❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 OTHER IDESCRBE M ITEM O.BELOW) D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A S.a: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOX D AND E ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM 95 UNKNOWN A. TYPE OF ❑ ❑ 99 OTHER SYSTEM ❑ 2 SINGLE WALL 4 SINGLE WALL IN A VAULT B. TANK ED1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ d STEEL CLAD W1 FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE7 9l.UMINUM ❑ B 100% METHANOL COMPATIBLE WIFRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 6 PHENOLIC LINING C.INTERIOR ❑ LINING OR ❑ 5 GLASS LINING ❑ 8 UNLINED 95 UNKNOWN 99 OTHER 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 91 NONE 95 UNKNOWN ❑ 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION ❑ SPILL CONTAINMENT INSTALLED(YEAR) OVERFlLL PREVENTION 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 UNKNOW 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 CRETE A U 7 STEEL WI COATING A U a 100% METHANOL COMPATIBLE W/FRP CORROSION A U S ALUMINUM A U fi CON PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 6 UNKNO A U 99 OTHER 1 MECNWfAL TIME IFNt 2 DME iIGHIMEad ❑7 fANTIM1IX15 WfERSR1ILL ❑4 ELECT80MC ILYE ❑5 AUf01MTG W W ❑ 99 OTHBR D. LEAK DETECTION ❑ r�E�oR ❑ rEsmw ubM7auMa IFAM °t°R 9P100'"" V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 ECONCIUATONORY ❑ 3 VAOOZS MONITORING ❑ 4 GAUGING AUTOMATIC TANK ❑ 5 GROUND WATER ❑6 ANNUAL TESTINGTANK ❑ 7 MONTOROUCSINTERSTTIAL ❑ 8 SIR ❑ 9 WEEKLYTANK MANUAL 1:110 MEOSNTHLY TING TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAY/YR) I 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES [:] NO❑ SUBSTANCE REMAINING GALLONS IN MATERIAL 7 IJ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT DATE TANK OWNER'S NAME (PRINTED d SIGNATUBET LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# m D PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIR O jBEENFILED. FORM C MUST BE COMPLETED FOR I r THIS FORM MUSTRM A HAS SHOULD BE ACCOMPANIED BY AI PLOT PILAN. FILE CATION-FTHIS ORM WITH THE LOCAL ORM A,UNLESS A CURRENT AGENCY IMPLEMENTING THE UNDERGROUND STTORA E TANK REULATIONNSNS.THISFORM FORMS (6-95)