BILLING - Laserfiche WebLink

Home Browse Search

�bourcea P •u•e• Cp i STATE OF CALIFORNIA • STATE WATER RESOURCES CONTROL BOARD p UNDERGROUND STORAGE TANK.PERMIT APPLICATION FORM B 8 • C9LIFGN Nor•. COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. LDBAOR Y ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT � CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED ll r CILITY NAME WHERE TANK IS INSTALLED: 12 Iic 4 1. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN a MANUFACTURED BY: A. OWNER'S TANK I.D.9 / (--<— D. TANK CAPACITY IN GALLONS: C. DATE INSTALLED(MOIDAYNFAR) 7 O II.TANK CO EMS IFA-11SMARKED,COMPLETEITEM C. aREGULAR ❑ 3 DIESEL ❑ 6 AVIATIONGAS A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. 1 PR©DUCT C 1b UNLEADED E ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ IUM 80 EMPTY ❑ UNLEADED ❑ 5 JET FUEL ❑ 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 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C.AND ALL THAT APPLIES IN BOX D 0 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN A. TYPE OF 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER _ SYSTEM 2 SINGLE WALL ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W!FIBERGLASS REINFORCED PLASTIC B. TANK 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑� 7 ALUMINUM ❑ B 1OC"/ METHANOL COMPATIBLE WIFRP MATERIAL. ❑ ❑ ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER (primary Tank) 9 BRONZE ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING E] 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED 5 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ N D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 4 FIBERGLASS REINFORCED PLASTIC 3 VINYL WRAP PROTECTION CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN 99 OTHER IV,PIPING INFORMATION CIRCLE A 1F ABOVE GRpt9jD OR U W UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION U PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCT{ON A U 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 WI COATING A U 8 100% METHANOL COMPATIBLE WIFRP 10 CATHODIC PROTECTION A a UNKNOWN A U 99 OTHER PROTECTION A U 9 GA NIZED STEEL A U I�I 3 INTERSTITAL Egg OTHER D. LEAK DETECTION AUTOMATIC LINE LEAK DE TEC �R 2 LINE TIGHTNESS TESTING LJ MIN V.TANK LEAK DETECTION ❑ i ❑� 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING VISUAL CHECK 2 INVENTORY RECONCILIATION 95 UNKNOWN El 99 OTHER TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ V1 TANK CLOSURE INFORMATION 3.WAS TANK FILLED WITH 2.ESTkMATED QUANTITY OF YES ❑ NO ❑ 1.ESTIMATED DATE LAST USED !YNI ) SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDp F IS TRUE AND CORRECT A PPLICANT'S NAME 8 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE l.D.# <3 y7PERM 7 PERMITNUMBERPERMIT APPROVED BY/DATE EXPIRATION DATE v I C� zr FORMS (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOR03373R4 46