BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

. ^ sraTEDFcauFORMa �t STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B COMPLETE A SEPARATE FORM FOR EAC TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 6 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED 09 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: F 7,S/ I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK LD.# O/ S. MANUFACTURED BY: UK C. DATE INSTALLED(MO/OAYA'EAR) [/�t I D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IFA•IISMARKED.COMPLETEITEM C. A. EkI MOTOR VEHICLE FUEL ❑ d OIL g, C ❑ 1a REGULAR 3 DIESEL ❑ ❑ UNLEADED 8 ❑ e AVIATION GAS 2 PETROLEUM BO EMPTY 1 PROWCT rI/10�'7PREMIUM d Ga5'1HOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ NLEADED ❑ 5 JETFUEL ❑ 7 METHANOL LIG 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOTMARKED, ENTER NAME OF SUBSTANCE STORED C.A S.s III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B.ANOC,ANDALL THATAPPLIES IN BOX A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM SINGLE WALL ❑ d SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ J FIBERGLASS ❑ d STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ B POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTFIER 1 RUBBER LINED 2 ALKYD LINING❑ ❑ 3 EPDXY LINING ❑ 6 PHENOLIC LINING C.INTERIOR LINING ❑ 5 GLASS LINING UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ D.CORROSION ❑ I POLYETHYLENE WRAP ❑�ING ❑ 3 VINYL WRAP ❑ d FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE T A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER A. SYSTEM TYPE A�1 SUC B. CONSTRUCTION A f��-, SIN E W A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A g/) IfE STEE A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U d FIBERGLASS PIPE CORROSION A V 5 ALUMINUM A U a CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U GALVAN2ED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 AUTOMATICLINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ IINMONROPINOL OTHER µpr-Z.r , V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ d AUTOMATIC TANK GAUGING ❑ 5 GROUND WALTER ❑ e TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN El OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH // g/ SUBSTANCE REMAINING Q GALLONS INERT MATERIAL? YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME (PRNTEO 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE LD.# 3 9 ] = - o / PERMIT NUMBER PERMIT APPROVED 8Y/OATE PERMIT EXPIRATION DATE FORM B 1990) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. • FOR06x8.Aa �1 _