BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA 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 a TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: tO E. GKY I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN LOWNER's TANK 1.D. B. MANUFACTURED I DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: ILTANKCONTENTS IFA-11SMARKED,COMPLETE ITEM C. A. ❑ i MOTOR VEHICLE FUEL 4 OIL B. C ❑ 1a3 DIESEL ❑ 6 AVIATION GAS UNLEADED 2 PETROLEUM ❑ 60 EMPTY ❑ 1 PRODUCT ❑ 1b PREMIUM 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN 2 WASTE UNLEADED ❑ 2 ❑ 99 OTHER (DESCRIBE IN ITEM 0. BELOW)5 JET Furl- D. UEL ❑ 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 ALLTHATAPPLIES IN BOX D AND A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 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 _] S 100% METHANOL COMPATIBLE W/FRP (Pfim6ryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER [:] 1 RUBBER LINED ❑ 2 ALKYD LINING E] 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ UNLINED 5 GLASS LINING 6 UNLI LINING ❑ 95 UNKNOWN 99 OTHER N♦ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO- D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE E::]95 UNKNOWN 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IFUNDERGROUN BOTH IF APPLICABLE A. SYSTEM TYPE Aj, 1 SUCTION A U 2 PRESSUREA.W3 GRAVITY p U 99 OTHER B. CONSTRUCTION 1 SINGLE WALL A U 2 DOUBLE WALL p U 3 LINED TRENCH p IJ 95 UNKNOWN A U 99 OTHER C. MATERIAL AND 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 B 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 ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 q MONITORING 99 OTHERV.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING. ❑ 91 NONE ❑ 95 UNKNOWN 99 OTHER VI.TANK CLOSURE INFORMATION 1.EST15/ATED9ATE LAST�JSED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH �� ((gyp' SUBSTANCE REMAINING GALLONS INERTMATERIAL? YES ❑ N THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME (PRINTED B SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW f�e C. Q 3 145,(, STATE LD.# COUNTY# JURISDICTION# FACILITY# TANK# m PERMIT NUMBER PERMITAPPROVED BV/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM B (12-91) • FILE THIS FORM WITH T LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS ) Q —q5 FOROMB R9