BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

• STATE OFCALIFORMASTATE WATER RESOURCES CONTROL BOARD • °" es UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT -`I'u 1• ONE ITEM 2 INTERIM PERMIT E] ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ON SITE q AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE DBA OR FACILITY NAME WHERE TANK IS INSTALLED: a TANK REMOVED I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.x B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) K c D. TANK CAPACITY IN GALLONS: II.TANKC ENT$ IFA-11SMARKED,COMPLETEITEM C. o D 0 A. 1 MOTOR VEHICLE FUEL ❑ q OIL g C. ❑ 1a REGULAR 7GASAH7OL ❑ 2 PETROLEUM O BO EMPTY UNLEA ❑ 6 AVIATIONGAS 1 PRODUCT ❑ 1bP IUM 3 CHEMICALPRODUCT 95 UNKNOWN 2 W TE LEADED ❑ ❑ 7 METHANOL D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED 2 LEADED ❑ BE IN IT D. BELOW) III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.8,AND C,AND ALL THAT APPLIES IN BOX D AND E CA.S.x: A. TYPE OF ❑/ DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER SYSTEM IL�J'2 4 GLE WALL ❑ ❑ 95 UNKNOWN SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 (Primary Tank) ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ gg OTHER ❑ 1 LASS ppppp�Il�I��J��y�++LINED 2 D LINING C.INTERIOR IL�J�'!/ ❑ 5 GLASS 3 EPDXY LINING 4 PHENOLIC LINING LINING ❑ LINING UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 700% METHANOL 7 YES_ NO D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ �AIND PROTECTION 3 VINYL Wqpp4 FIBERGLASS REINFORCED PLASTIC ❑ 5 CATHODIC PROTECTION ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND O-------------- VERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) 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 B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 GRAVITY A 99 OTHER A U 3 LINED TRENCH A NK C. MATERIAL AND A U 1 BARE STEEL N A U 99 OTHER CORROSION A U S ALUMINUM A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE PROTECTION A U 6 CONCRETE A U 7 STEELW/COATING A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION S UNKNOWNA U 9 100% METHANOL COMPATIBLE W/FRP D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTINGA U 99 OTHER V.TANK LEAK DETECTION MONBOgING ❑ss OTHER_ ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 OZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATE ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING 91 NONE ❑ 95 UNKNOWN VI.TANK CLOSURE INFORMATION ❑ a9 OTHER i.ESTIMATED DATE AST USED(MO/D /YR) 2.ESTIMATED QUANTITY OF SUBSTANCE REMAINING D GALLONS 3 WAS TANK FILLED INERTMATERIAL9H YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF My KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME )PRINTED A SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I .NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# STATE LD.# TANK � gIs PERMITNUMBER PERMIT APPROVED BV/DATE D PERMIT EXPIRAT,g1NgpTE FORM 8 (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. /� 0 0 Po 101