BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA • STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B oM1 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. 1 [DBA;ORI ONLY ❑ 1 NEW PERMIT c• ITEM ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION I� ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ L ,7 PERMANENTLY CLOS N SITE 6 TEMPORARY TANK CLOSURE /�ijo`I FACILITY NAME WHERE TANK IS INSTALLED: a $ 8 TANK REMOVED /. I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN V A OWNER'S TANK I.D.Y B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) q T D. TANK CAPACITY IN GALLONS- 11.II.TANNKy CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A �L 1 MOTOR VEHICLE FUEL ❑ 4 OIL B C. [—jlaREG 2 PETROLEUM ULAR UNLEADED 3 DIESEL ❑ 6 AVIATION GAS ❑❑ E] 80 EMPTY �4-PRODUCT ❑ 1b PREMIUM UNLEADED 4 GASAHOL ❑ 7 METHANOL 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ is MIDGRADE UNLEADED ❑ 5 JETFUEL ❑ 8 M85 D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C.AND ALL THAT APPLIES IN BOX D AND E C.A S.Y: A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ll�2 SINGLE WALL ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK K, BARE STEEL ❑ 2 STAINLESS STEEL MATERIAL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC ❑ 5 CONCRETE E] 6 POLYVINYL CHLORIDE 7 ALUMINUM (Primary Tank) El 9 BRONZE ❑ ❑ 8 1METHANOL COMPATIBLE W/FRP ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN OTH ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING LINING OR 555y��..,,,////6 ❑ 3 EPDXY LINING E] 4 PHENOLIC LINING ❑ 5 GLASS LINING IJKI UNLINED COATING �'""� ❑ 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO RIOR D CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING I��g ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 1 NONE ❑95 UNKNOWN E.SPILL AND OVERFILL,6IC. SPILL CONTAINMENT INSTALLED q) ❑ 99 OTHER DROP TUBE YES NO PLATE YES OVERFILL PREVENT) EQUIPMENT INSTALLED(YEADISPENSER CONTAINMENT YES_ NO R) IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR Up UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 4 F BLEPIPING A U 99 OTHER A U 3 LINED TRENCH p U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL p U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U S ALUMINUM PROTECTION A U 6 CONCRETE A U 7 STEELW/COATING A UO9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 8 100% METHANOL COMPATIBLE W/FRP D. LEAK DETECTION ❑1 Dl� 4TCTE� uNE)FAN 2 TFSTING 3 CQVTINUON6 LINE N.-M-S$ A U 95 UNKNOWN A U 99 OTHER_ FAX DETECTOR❑ INTEPSR11gL O 1 ELECmGM UNE ❑5 At%WVC1yN WMT El 99 OTHER V.TANK LEAK DETECTION Nox9URINa tSHUIOp ❑ 1 VISUAL CHECK 8 VADOZE MANUAL INVENTORY ❑ 3 MONITORING 4 AUTOMATIC TANK 5 GROUND WATER 6 ANNUAL TANK ❑ 7 CONTINUOUS INTERSTITIAL ❑ GAUGING ❑ MONITORING ❑ 8 SIR ❑ 9 WEEKLY MANUAL ❑10 MONTHLY TANK MONITORING TESTING Vi.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE)NK GAUGING TESTING ❑ 95 UNKNOWN ❑ 99 OTHER 1.ESTIMATW DATA LA$'{USED YNR) 2.ESTIMATED QUANTITY OF y�y, v SUBSTANCE REMAINING G!O GALLONS 3 WAS TAN FILLEDMATERIWI, H YES ❑ NO �I TI-11S FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT [—TAN OWNER'S NAME (PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY THESTATEI.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# STATELD:# � TANK# PERMIT NUMBER PERMIT APPROVED BYAJATE PERMIT EXPIRATION DAT THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PIfILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE RGROUND STOP GE TANK REGULATIONS FORM B (6-95)