BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

• STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION . FORM B > , I COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: �t I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.N B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) 17 D. TANK CAPACITY IN GALLONS: -- II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A ,'�� 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C, ❑ la REGULAR UMEADED 3 DIESEL ❑ B AVIATION GAS lb PREMIUM UNLEADED 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT �,-"1c MIDGRADE UNLEADED H 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 OTHER(DESCRIBE IN REM D.BELOW) D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.a: 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 ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 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) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP LJ 4 FIBERGLASS REINFORCED PLASTIC CORROSION ❑ ❑ PROTECTION ❑ 5 B1 NONE 95 UNKNOWN 99 OTHER CATHODIC PROTECTION ❑ - SPILL CONTAINMENT I"ALLED(YEAR) OVERFILL PR,VENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,9I0. DROP TUBE VES NO_ STRIKER PLATE YES�/ NO DISPENSER CONTAINMENT YES NO IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPUCABLE A. SYSTEM TYPE A U 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.b 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(Qi 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% 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 01 IA[cxu&cu.UNE HUK z UNE TKYRNE55 3 catRw=WrEB Q 4 E1Ec C uNE qs AvrouAnc PUMP ❑ 99 OTHER OE1ELfOR UNE Ta 40NfORN3 ffAx OEIECTOR 9NrWWX V.TANK LEAK DETECTION F7 1 VISUAL CHECK ❑ 2 RMANUAL ECONCILII TIONORY ❑ 3 MONIITORING h VAOZE4 GAUGING AUTOMATIC TANK E]5 MON TORINGGROUND WATER ❑ 8 TESTINGANNUAL ❑ 7 MONITOR UG INTERSTITIAL ❑ 8 SIR ❑ 9 WEEKLY MANUAL E::]10 TESTING Y TANK [-] 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED DATE LAST USED(MO/DAWYR) 2.ESTIMAQUANTITY OF 3.WAS TANK FILLED WITH yE5 ❑ NO❑ SUBSTANCTEDE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANKOWNER'S-NAME (PRINTED&SIGNATUR) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY It JURISDICTION M FACILITY B TANK M STATE I.D.# m PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLIC ON-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOR�A C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT Pw11 THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THFsRGROUND STORAGE TANK REGULATIONS FORME (6.95)