BILLING - Laserfiche WebLink

Home Browse Search

v ! 10-11-oy Oq 1� �Z�� f�STATE OF CALIFORNIA J STATE WATER RESOURCES CONTROL BOARD . UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B , Itl; . COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY [] NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ON SITE ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: LD �� t a3 0'l 8 I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNER'S TANK I.0.M ,j/J 738 B. MANUFACTURED Sr. C. DATE INSTALLED(MWAYNEAR) 0. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. 1a RE UNLEADED ❑ 3 DIESEL ❑ 8 AVIATION GAS A ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL 8. C' ❑ lb PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT ❑ 1C MIIX3MOE UNLEADED O 5 JET FUEL ❑ B M85 ❑ 3 CHEMICAL PRODUCT �95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN REM D.BELOW) D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A S.p III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B,AND C.AND ALL THAT APPLES IN BOX D AND E A. TYPE OF ❑ I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM [:195 UNKNOWN SYSTEM � SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER J BARE STEEL F72 STAINLESS STEEL ❑ 3 FIBERGLASS E] 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE F78 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER F7 RUBBER LINED F72 ALKYD UNING ❑ 3 EPDXY UNING ❑ 4 PHENOLIC UNING C.INTERIOR �D5 UNKNOWN ❑ 99 OTHER LINING OR ❑ 5 GLASS LINING ❑ B UNUNED COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.E 7ERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION g1 NONE ❑95 UNKNOWN ❑ PROTECTION 99 OTHER F75 CATHODIC PROTECTION SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E SPILL AND OVERFILL,aTC. DROP NBE YES_ NO_ STRIKER PLATE YEB_ NO_ DISPENSER CONTAINMENT YES_ NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U S: SUCTp A U 2 PRESSURE A U 3 GRAVITY A U A. FLEXIBLE PIPING A- U 99 OTHER B. CONSTRUCTION A U SINGLE�WALL A U 2 DOUBLE WALL A U 3 UNED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BRE STE A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 8 CONCRETE A U 7 STEEL W/COATING A U B 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER CC 1 MECNANCAL UXE IF.AI( 2 UNE PGIONESa ❑3 MONLDRNG LYIEP51111AL ❑d LEAN CTOR ❑5 9�AIL0�0nNrCl PUMP ❑ 99 OTHf:Fi 0. LEAK DETECTION ❑ oEl>:cren ❑ TEsnxa V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCILIATIONORV ❑ 3 MONIITORING ❑ 4 GAUL NG AUTOMATIC TANK ❑ 5 GROUND MONITORINGTER ❑ 8 ANNUAL EST NGTANK ❑ 7 CON INU U INTERSTITIAL ❑ 8 SIR ED WEEKLYANK MANUAL ❑1O TESTING TANK ❑ 95 UNKNOWN .�c� OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 2ESTIMATEDOUANTITYOF / 3.WAS TANK FILLED WITH YES [:] NO� 1.ESTIMATED DATE LAST V �(MO/OAY/VR) SUBSTANCE REMAINING ONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJ RY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT DATE TANK OWNER'S NAME < (PRIN11D 491GNATURET (-/ ((� LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW (� COUNN# JURISDICTION J FAC7= =T STATE I.D:# m PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE T FORM A HAS BEEN FILED. FORM C MUST BE D FOR THIS FORM MUSTSHOULD BE ACCOMPANIED BY AI PLOT PLAN. FILE ILEFTHIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STTORM A,UNLESS A CURREN ORAGEE ANK REGUL.AiIDNSNS THIS FORM FORMS (695)