BILLING - Laserfiche WebLink

Home Browse Search

ru.r.. co s STATE OF CALIFORNIA s� o • STATE WATER RESOURCES CONTROL BOARD w.mom UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B CiL,roq Nor 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 ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 6 TANK REMOV Z .� r9 DB AOR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# � B. MANUFACTURED BY: C. DATE INSTALLED(MOlDAYA'EAR) ?Cc� D. TANK CAPACITY IN GALLONS: d IIJANKCONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. n i MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1aUN UNLEADED REGULAR 3 DIESEL 7 METHANO6 AVIATION L A 4 GASAHDL ❑ ❑ 2 PETROLEUM BO EMPTY PRODUCT UNLEADED ❑ F 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 C.A.S. III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND RLL THAT APPLIES IN BOX D ❑ I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN A. TYPE OF 99 OTHER SYSTEM GLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) EEL �B�2TAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK OLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100°/ METHANOL COMPATIBLE W/FRP MATERIAL �5�NECTE (Primary Tank) ❑ 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 UNLINEDUNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH i00% METHANOL 7 YES_ NO_ ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC D.CORROSION 99 OTHER PROTECTION ATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ IV.PIPING INFORMATION CIRCLE A IFABOVEGRO DOR U IF UNDERGROUND,BOTFIIFAPPLICABLE A. SYSTEM TYPE A U 1 SUCTION RESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A 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 5 W7 COATING A U B 100% METHANOL COMPATIBLEWlFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION U, 9 UNKNOWN A U 99 OTHER 31NTERSTITIAL 99 OTHER D. LEAK DETECTION AUTOMATIC UNE LEAK DETECT)R 2 LINE TIGHTNESS TESTING MONITORING V.TANK LEAK DETECTION I V CHECK INVENTORY RECONCILIATION ❑ 3 VAPOR 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 ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH 2, i.ESTIMATED DATE LAST USED(MOIDAYIYR) SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES ❑ NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT DATE APPLICANT'S NAME (PRINTED$SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# � F� PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE `1 FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOR0034B-R4 (,;7if