BILLING - Laserfiche WebLink

Home Browse Search

• • STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD NDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B Y 1� COMPLETE A SEPARATE FORM FOR EAC TANK SYSTEM, c "p�,• MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 9 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: / 3 S. S 4..44, I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MODAY/Y AR) D. TANK CAPACITY IN GALLONS: /a II.TANK CONTENTS IF A-1 IS MARKED,COMPwrfITEM C. REGULARInI��I ❑ 1 MOTOR VEHICLE UEL 4 OIL B. C. ❑ 18UNLEA ED u 3 DIESEL ❑ g AVIATION GAS A. u 4 JET FUEL ❑ 2 PETROLEUM ❑ 00 EMPTY 1 PRODUCT ❑ 1bUN UNLEADED 5 JET FUEL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODU T ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, EN#R NAME OF SUBSTANCE STORED C.A.S.s: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C,AND ALL THAT APPLIES IN BOX D AND A. TYPE OF ❑ 1 BLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SI WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER 1 SalM STEEL ❑ 2 STAINLESS STEEL ED3 FIBERGLASS ❑ 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORITE ❑ 7 ALUMINUM ❑ g IODK METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 AAAGGGAAAALLVVVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER F-11 RUBBER LINED ❑ Z LWING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING —L�4, 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 CO G ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED-PLASTIC. PROTECTION ❑ 5 CATHODIC PROTECTION 1 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL 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 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 1 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 a IDD% 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 ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TGHTNESS TESTING ❑ NONRORING ❑99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK � 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING❑ 5 GROUNDWATER MONITORING ❑ 6 TANK TESTING E:] 7 INTERSTITIALMONIORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED�(MOIDAY/YR) 2.ESTIMATED QUANTITY OF ® 3.WAS TANK FILLED WITH YES ❑ NO u 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 (PRINTED 6 SIGNATURE( LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# c- STATE I.D.# 1 1 21313 11 PERMITNUMBER PERMIT APPROVED BY/DATE PERMITEXPIRATION DATE (5 FORM B (7.91) THIS FORM MUST BE ACCOMPANIED BY A.PERMR APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. • • � F RS