Laserfiche WebLink
STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM E <br /> COMPLETE A SEPARATE FORM FOR EA TANK SYSTEM. <br /> M�4 K ONLY 1 NEW PERMIT 3 RENEWAL PERMIT S CHANGE OF INFORMATION j j 7 PERMANENTLY CLOSED ON SIT' <br /> ONE ITEM 2 INTERIM PERMIT a AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOV— <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: k�l& z/ , <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN ' <br /> A. OWNER'S TANK I.D.or B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAY.NEAR) — D, TANK CAPACITY IN GALLONS: <br /> II.TANK CONTENTS IFA•1ISMARKED,COMPLETE ITEM C. fn117 <br /> A. X 1 MOTOR VEHICLE FUEL 4 OIL to REGULAR 1 <br /> B. C. �I 3 DIESEL 6 AVIATION GAS 4 <br /> UNLEADED �Ll <br /> 2 CHEMICAL <br /> ALP 80 EMPTY 1 PRODUCT ib PREMIUM 4 GASAHOL 7 METHANOL <br /> 3 CHEMICAL PRODUCT El <br /> 95 UNKNOWN 2 WASTE UNLEADED 5 JET FUEL <br /> ED 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW1 <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,6,AND C,AND ALL THAT APPLIES IN BOX D AND E <br /> A. TYPE OF I 1 DOUBLE WALL E:l 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALL L7 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER <br /> B. TANK 71 1 BARE STEEL 2 STAINLESS STEEL ll;;;f 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REPNFORCEO PLASTkC <br /> MATERIAL ❑ 5 CONCRETE 6 POLYVINYL CHLORIDE Y'��7 ALUMINUM B 100% METHANOL COMPATIBLE W/FRP <br /> (PrirnaryTank) 9 BRONZE ❑ TO GALVANIZED STEEL 95 UNKNOWN 99 OVER <br /> C.INTERIOR <br /> 1 RUBBER LINED C 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINfNG <br /> �' <br /> LINING C 5 GLASS LINING6 UNLINED 95 UNKNOWN 99 OTHER <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES NO <br /> D.CORROSION J 1 POLYETHYLENE WRAP 2 COATING 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION 91 NONE 95 UNKNOWN 99 01-HER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> 1V.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A U 1 BARE STEEL A 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE WIFRP <br /> PROTECTION A U 9 GLVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A�UggTHERD. LEA=EAK <br /> �DETECT�ION '�� <br /> MDNTORikG99 OTHER <br /> V.TAN <br /> 1 VISUAL CHECK IJ 2 INVENTORY RECONCILIATION 3 VAD07_E MONITORING 4 AUTOMATIC TANK GAUGING 5 GROUND WATER MONITORING <br /> C 6 TANK TESTING 7 INTERSTITIAL MONITORING 91 NONE Q 95 UNKNOWN 99 OTHER <br /> VI.TANK CLOSURE INFORMATION_ <br /> i.ESTIMATED TEAAST S D(MOIDAYlYR) d 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES ND <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO TlgE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME <br /> (PRINTED 6 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK# <br /> STATE ].!).# I05 11 <br /> �� <br /> PERMIT NUMBER PERMIT APPROVED BYlDATE PERMIT EXPIRATION DATE <br /> THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM B (12-91) <br /> FOR0034&R6 <br /> �,.," `` 1 n 1 .—Cid ►'� <br /> 4 <br />