BILLING - Laserfiche WebLink

Home Browse Search

w �rd r STATE OF CALIFORNIA o STATE WATER RESOURCES CONTROL BOARD a W4a,' UNDERGROUND STORAGE TANK PERMIT APPLICATION •FORM B :^ COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. ❑ 5 CHANGE OF INFORMATION PERMANENTLY CLOSED ONSITE 1 NEW PERMIT ❑ 3 RENEWAL PERMIT S TANK REMOVED MARK ONLY ❑ E 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ONE ITEM ❑ 2 INTERIM PERMIT 09 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: D I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN B MANUFACTURED BY: A. OWNERS TANK I.D.% D. TANK CAPACITY IN GALLONS: C. DATE INST ED(MO/DAV/VEAR) ILTANK INTENTS IFA-11S MARKED,COMPLETE ITEM C. 1a GULAR ❑ 3 DIESEL ❑ 6 AVIATIONGAS 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ NLEADED ❑ 4 GASAHOL ❑ 7 METHANOL A ❑ 2 PETROLEUM ❑ SO EMPTY 1 PRODUCT ❑ PREMIUM ❑ 5 JETFUEL ❑ 3 CHEMICALPRODUCT ED95 UNKNOWN ❑ 2 WASTE 2 LEADED E::] 99 OTHER (DESCRIBE IN ITEM D. BELOW) 0. IF(AA)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BO%ESA,O,AND C,AND ALL THAT APPLIES IN BOX D ANDS ❑ ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN A. TYPE OF 1 DOUBLE WALL 99 OTHER SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIO0!GIENFORCED PLASTIC B TANK ❑ 8 100% METHANOL COIFRP MATERIAL F. 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM (Primary Tenk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? VES_ NO_ ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFTIC D.CORROSION gt NONE ❑95 UNKNOWN 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION ❑ E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EOUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 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 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 /UNKNOWN A U 991000%% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U5 A 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ MONRORING ❑ V,TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 3.WAS TANK FILLED WITH 2.ESTIMATED QUANTITY OF YES [:] NO 1.ESTIMATED DATE STU E (MOI YR) SUBSTANCE REMAINING _GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGEE IS TRUE AND CORRECT APPLICANTS NAME (PRINTED a SIGNFTURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# 0ll�/ STATE I.D.# alb PERMIT NUMBER PERMIT APPROVED BV/DATE PERMIT EXPIRATION DATE THIS FOHM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK /REGULATIONS FOROf0A8-R6 FORM B (12-91) • /J v