BILLING 1985-1992 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA • '� ` STATE WATER RESOURCES CONTROL BOARD s•� '.y c UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B >+ o C/ COMPLETE A SEPARATE FO FOR CH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT !,CHANGE OF INFORMATION ❑ 7 PERMANENTLY OSE SITE ONE ITEM ❑ 2 INTERIM PERMIT d AMENDED PERMIT 6 TEMPORARY TANK CLOSURE' ❑ 8 TANK REMOVE c� DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ? 72,e± f6 V!�) e-Ac I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.a L ^ B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAY/YEAR) ' l� D.TANK CAPACITY IN GALLONS: Q rr ,D ILTANKCONTENTS IFA-11SMARKEO,COMPLETE ITEM C. REGULAR �I F-11 MOTOR VEHICLE FUEL ❑ d OIL B. C. ❑ 1aUNLEA ED 'r—I 3 DIESEL ❑ 8 AVIATION GAS A. ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT ❑ PREMIUM LLJ�I d GASAHOL Ib 7 METHANOL UNLEADED 5 JETFUEL ❑ ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 OTHER (DESCRIBE IN ITEM 0. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.s: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.S.AND C.AND ALLTHAT APPLIES IN 80X0 A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ d SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER ❑ B. TANK i BARE STEEL ❑ 2 STAINLESS STEEL C:] 3 FIBERGLASS ❑ d STEEL CLAD W1 FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ e POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LNWG ❑ 3 EPDXY LINING ❑ d PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ d FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN 99 OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U I 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 d FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL WICOATING A U 8 100% METHANOL COMPATIBLE WIFRP 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 TIGHTNESS TESTING ❑ T MONRTITAL ❑ 99 OTHER r ORING V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ d AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING 8 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION I.ESTIMATED DATE LAST USED(MO/DAY/YR) 2 ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO ❑ 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 S-�"'�Z IV/-) IPRPLIC aTSNAME LOCAL AGENCY USE ON./LY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW 0IV 37 COUNTY# JURISDICTION# FACILITY# TANK# STATE I. .# / 3 ®v PERMITNUMBER I PERMITAPPROVEOBYA]ATE I PERMIT EXPIRATION DATE FORMS (9-911) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM&"