BILLING - Laserfiche WebLink

Home Browse Search

r I STATE OF CALIFORNIA �� i• STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. - MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ON,S,IT ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE BANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: UYT 0. � o '5Azov" --' I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN • I A OWNER'S TANK I.D.X (A11 JRED BY: &4 C. DATE INSTALLED(MO/DAYNEAR) IA D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS A. F-1 2 PETROLEUM ❑ BO EMPTY PRODUCT .❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL 1L�J 1c MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOM D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.k: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C.AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF �❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM L,/I 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ® 1 BARE STEEL E:] 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) E7*4'"BRONZE 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATINGLg UNING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— D•EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION '� PROTECTION E] �'pJ 5 CATHODIC PROTECTION L91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,BLL. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES NO STRIKER PLATE YES_ NO_ DISPENSER CONTAINMENT YES NO IV, PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U I 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 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U B 10096 METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 MECHANICAL UNE LEAN 0 2 UNi MWNES 3 CCNm1MW8 MTER3TI141 4 F1ECmQNIC LINE O 5 AmCLIATIC PMMP O B9 OTHER DETECTOR TE&TMo MOMTMG LEAN oETEOTOR VIRtM M V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL RECONCILIATIONORY O 3 VADEMONITORING ❑ 4 AUTOMAnGAUGING C TANK ❑5 GROUND MONITORING TER ❑ 6 ANNUAL TESTING ❑ 7 MONITORING INTERSTITIAL ❑ 8 SIR ❑ 9 TAENK GAUGINGAL ❑10 TESTING TANK ,� 95 UNKNOWN ❑9B OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO,�j SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AN2 TO THE BET OF MY KNO LEDGE,IS TRUE ANMCOR ECT TANK OWNER'S NAME1 �{/"/ DATE (PRINTED&SIGNATURE) /.r��. MC LI^1 it - Q V"/,.P r I ✓L I, LOCAL AGENCY USE ONLY THE STATE I.D.NUM4ER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.Dl m = Q PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACC(SMPANIED BY A PERMIT APPN•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED.MMIC MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PWLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THIWRGROUND STORAGE TANK REGULATIONS FORM B (6-95)