BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA °"OVP;°c° STATE WATER RESOURCES CONTROL BOARD ^' i= UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B : `� COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM 'r,.o� MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT ❑ Y ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ? PERMANENTLY CLOSED ONSITE ❑ ❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: CF, 4v" I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.i v'4� B. MA�GAPACiTwY BY: C. DATE INSTALLED(MO'DAY/YEAR) v D. TAN GALLONS: 00 II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A. ; MOTOR VEHICLE FUEL ❑ 4 OIL B- C ❑ 1a REGULAR 3 DIESEL F-1 ❑2 PETROLEUM - UNLEADED ❑ 6 AVIATIONGAS Ba EMPTY / PRODUCT ❑ 1b EMIUM 4 GASAHOL ❑ ? METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADEDD ❑ 5 JET FUEL ❑ 99 OTH D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED ER (DESCRIBE IN ITEM D. BELOW) C.A.S.i: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C.AND ALL THAT APPLIES IN 13OXD A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER �g5 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ N OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS O 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ T UMINUM ❑ 6 100% METHANOL COMPATIBLE W/FFIP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ eg OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 8 UNLINEDu�,/96 UNKNOWN E::] 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING Il 3 yINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE L^may-5/UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U / 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(3r�05 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 T STEEL W/COATING A U 6 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION er-a5 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING 1111-111MIL E]MONITORINGG 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4AUT IC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ T INTERSTITIAL MONITORING E::] 91 NONE UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAV/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING 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 APPLICANT'S NAME (PRINTED!SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# F _ TANK# STATE I.D.# PERMITNUMBER PERMIT APPROVED BYIDATE IT EXPIRATION DATE :17. /l FORM B (990) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. a FOROa 138 4