BILLING 1986-1999 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA • •"'�� o STATE WATER RESOURCES CONTROL BOARD 3`• I UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B W e COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM, [MARKONLY 1 NEW PERMIT 3 RENEWAL PERMITTEM ❑ 2 INTERIM PERMIT ❑ ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLO .gry,glTE ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE v8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.♦ l.1 B. MANUFACTURED BY: /i/� 1/ C. DATE INSTALLED(MO/DAV/YEAR) n/� /] W�III� er�li `( D. TANK CAPACITY IN GALLONS: II.TANK NTENTS IFA-11SMARKED,COMPLETEITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B- C la REGULAR o 3 DIESEL o2 PETROLEUM UNLEADED ❑ 4 GASAHOL ❑ 6 AVIATIONGAS ❑ 80 EMPTY 1 PRODUCT ❑ lb PREMIUM ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE UNLEADED ❑ 5 JET FUEL ❑ ❑ IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED 2 LEADED 99 OTHER (DESCRIBE III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C.AND ALL THAT APPLIES 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 ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTeak) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ C.INTERIOR 1 RUBBER LINED ❑ 2 ALKYD LINING E::] 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER 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 ❑ 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U i SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN p 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 p U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN p B 99 OTHER D. LEAK DETECTION O 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ O A MONROPING ❑99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE 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 L ESTI A 0 AjT T ED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF `'YSUBSTANCE REMAINING 3.WAS TANK FILLED WITH YES NO GALLONS INERT MATERIAL 7 ❑ THIS F04M HA BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME (PRINTED a SIGNATDRE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE I.D.# COUNTY# JURISDICTION# FACILITY# TANK# = � Iv�� PERMIT NUMBER PERMIT APPROVED BLV/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORMA,UNLESS A CURRENT FORMA HAS BEEN FILED. FORM B (12-91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS ob0 FOR00348-116