BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

• • "GGOVF STATE OF CALIFDRMp STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION. FORM B COMPLETE 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 8 TANK REMOVED F-yV DBA OR FACILITY NAME WHERE TANK IS INSTALLED: V5 07 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# B. MANUFACTURED BY: I� C. DATE INSTALLED(MO/DAY/YEAR) uov, D. TANK CAPACITY IN GALLONS: j 0-o-0 H.TANK CONTENTS IFA-I ISMARKED,COMPLETE ITEM C. A. N�i MOTOR VEHICLE FUEL ❑ 4 OIL B. C� laREGULAR ED 3 DIESEL ❑ 6 AVIATIONGAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT PREMIUM L_1 4 GASAHOL 7b ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ UNLEADED ❑ 5 JETFUEL ❑ 7 METHANOL ❑ 2 LEADED ❑ g9 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 ALL THAT APPLIES IN BOX A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ��11 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK Id 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 5 GLASS LINING 1 RUBBER ER LINED ❑Id 2 ALKYD LINING ❑ 3 EPDXY LINING 4 PHENOLIC LINING C.INTERIOR T�yB UNLINED LINING ❑ ❑ 95 UNKNOWN ❑ 92 OTHER IS LINING MATERIAL COMPATIBLE WITH 10D% METHANOL? YES_ NO— D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ®95 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFA13OVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A 6)g9 OTHER U N k B. CONSTRUCTION A U I SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A©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 W/COATING A U 6 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODICPROTECTA©95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR Q 2 LI NE TIGHTNEIONSS TESTING3INTERSTITIAL ❑ MONRORING OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING IC491 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DTTJ LASf USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING �GALLONS INERTMATERIAL7 YES ❑ N�Tfigg THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLED APPLICANTS NAME GE, IS TRUE AND CORRECT (PRINTED a SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FA�C-IL�ITY# � TANK# STATE 1.D.# \ 9 =E1 F V I WRQ 0 O p PERMITNUM PERMIT APPROVED BY/DATE I— PERMIT EXPIRATION DATE FORM B (9.g0) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOROMS.1r\R/