BILLING - Laserfiche WebLink

Home Browse Search

• • e«a STATE OFCALIFORNIA STATE WATER RESOURCES CONTROL BOARD ;? 3 UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B W f . o COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO N SITE ONE ITEM ❑ 2 INTERIM PERMIT A AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ❑ 9 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: vell( I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A. OWNERS TANK I.D.a D a. MANUFACTURED BY: C. DATE INSTALLED(MODAYNEAR) 1.--� D. TANK CAPACITY IN GALLONS: vv _ 11.TANK C EMS IFA•IISMARKED,COMPLETEITEM C. A 1 MOTOR VEHICLE FUEL ❑ 6 OIL B. C. ❑ to REGUL R 3 DIESEL ❑ 8 AVIATION GAS ❑ 2 PETROLEUM ❑ BO EMPTY 1 PRODUCT ❑ Ib PREMIUM a GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICALPRODUCT 95 UNKNOWN 2 WASTE UNLEADED 5 JET FUEL❑ ❑ ❑ 2 LEADED 9g OTHER (DESCRIBE IN ITEM D. 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.B.ANO C.AND ALLT14AT APPLIES INBOXD A. TYPE OF ,❑—, 1 BLE.WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM Ly/2 S LE WALL ❑ d SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ a STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 1005 METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ _3t LINING ❑ s PHENOLIC LINING C.INTERIOR F-1S GLASS LINING ❑ 8 UNLINED 95 UNKNWN ❑ 99 OTHER - LINING IS LINING MATERIAL COMPATIBLE WITH 1005 METHANOL? YES_ NO D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 L WRAP ❑ s FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 5 UNMOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFASOVEGRW_NDO UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A u A A U 3 GRAVITY A U 99 OTHER 3. CONSTRUCTION A U 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 A FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U a CONCRETE A U 7 STEEL W/COATING A U 8 1005 METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHOOICPROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3INTER T"LMCNFrRWG ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING[:] 6 OMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING 1:38 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED NR) 2.ESTIMATED CUANTITV OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING 422_() GALLCNS1 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 DATE IPRKED a SIGNAMFIEI LOCAL AGENCY USE ONLY THE STATE LD.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# alI I I idp / y1 11019/1 PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE FORM B (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOR0011&Rl