BILLING - Laserfiche WebLink

Home Browse Search

• STATE OF CALIFORNIA n STATE WATER RESOURCES CONTROL BOARD IJYkI UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B W K; COMPLETE A SEPARATE FORM FOR H TANK SYSTEM. °' •a�' o MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ T PERMAN SED ONSITE ❑ ❑ 8 TEMPORARY TANK CLOSURE B TANK O DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN V A. OWNER'S TANK I.D.# O B. MANUFACTURED BY: G DATE INSTALLED(MO/DAVA'EAR) 0. TANK CAPACITY IN GALLONS: II.TANK NTENTS IFAIISMARKED.COMPLETEITEMC. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1aUNLEADEO 3 DIESEL ❑ g AVIATION GAS ❑ 2 PETROLEUM ❑ BO EMPTY 1 PRODUCT ❑ 1EPREMIUM 4 GASAHOL 7 METHANOL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 UNLEADED LEAD D ❑ 5 JET FUEL ❑ D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) III. TANK CONSTRUCTION MARKONEITEMONLYINBOXESA,B,ANDC,ANDALLTHATAPPLIESINBOXDANDE A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER SYSTEM ❑ 2 SINGLE WALL ❑ 95 UNKNOWN ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ d STEEL CLAD W7 FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 100% METHANOL COMPATIBLE W/FRP (Primwy T&nk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL 7 YES_ NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE �95 UNKNOWN ❑ 99 OTHER E.SPILLAND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE =DETECTION [�] PE A U 1 SUCTION p U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER TION A U 7 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN p U 99 OTHER AND A U / BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE N A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELW/COATING N A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 6 100% METHANOL COMPATIBLE W/FRP A U 95 UNKNOWN p U 99 OTHER CTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 31,IONRORING ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING D 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING FL 6 TANK TESTING ❑ 7 IN TERSTITIAL MONITORING ❑ 97 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF SUBSTANCE REMAININGNO 3.WAS TANK FILLED WITH GALYES ❑ ❑ 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 IPBINTEO A SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COJUNjTTY�# JURISDICTION FACILITY# TANK# FPERMITNU—MBER ATE LD.# �ZIU�I Q� 2 •`-�PERMIT APPROVED BY/DATE P RMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM B (12-91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATI S I�ORORN