BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

a STATE OF CALIFORNIA 0STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM BCOMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE p �/"TANK REMOVED 0 OBA OR FACILITY NAME WHERE TANK IS INSTALLED: 4 D 0 ")BS �.E'vn,e- <5 /� n I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) ' S`' D. TANK CAPACITY IN GALLONS: I `-5 II.TANK C ENTS IFA-11SMARKED,COMPLETEITEM C. 1 MOTOR VEHICLE FUEL 4 OIL B. C. aREGULAR ❑ 3 DIESEL 6 AVIATIONGAS A. ❑ UNLEADED ❑ ❑ ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 1bUNLEADED ❑ 5 JET FUEL 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B. O C.AND ALL THAT APPLIES IN BOX A. TYPE OFI❑ 111 DOUBLE WALL ❑ 3 SINGLE WALL ITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM I Z SINGLE WALL ❑ 4 SECONDARY CO TAINMENT (VAULTED TANK) ❑ 99 OTHER BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORID ❑ 7 ALUMINUM ❑ 9 1009: METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE El _L GALVANIZED STEEL B6 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED n 2�LKYD LINING 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING 6 UNLINED 95 NOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP 2 COATING ❑ 3INYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION F75 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 KNOWN ❑ 99 OTHER IV,PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH I PPLICABLE A. SYSTEM TYPE AQ U 1 SUCTION A U 2 PRESSURE A U 3 GRA A U 99 OTHER B. CONSTRUCTION A SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED ENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINY CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELWIC TING A U 6 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UN OWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING 3 MONRORINOL E:]99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING[::] 4 AUTOMATIC\ANK GAUGING ❑ 5 GROUND WATER MONITORING 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING E] 91 NONE ❑ 95 UNKNOW ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAS USED(M AV/VR) 2.ESTIMATED QUANTITY OF 3.WA TANK FILLED WITH SUBSTANCE REMAINING GALLONS ERTMATERIAL7 YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KN VLEDGE, IS TRUE AND CORRECT APPLICANTS NAME A I DATE (PRINTED a SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# PERMITNUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORM 8 (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. In..��,-+7 IJ R0934&RO