BILLING - Laserfiche WebLink

Home Browse Search

u« e STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B ?a COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWAL PERMIT M 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT F74 AMENDED PERMIT 7 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED i DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 115-7 D C I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.Q# f B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: lilnk ILTANKCONTENTS IFA-11S MARKED,COMPLETE ITEM C. A ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C ❑ 1aUNLEADED ❑❑lbPREMIUM 3 DIESEL ❑ 6 AVIATION GAS 4 GASAHOL F-1 80 EMPTY I ET UNLEADE EMPTY ❑ 3 CHEMICAL PRODUCT U �95 UNKNOWN ❑ 2 WASTEMETHANOL CT ❑ 2 LEADED D ❑ gg�OTHER L(DESCRIBE IN7ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.4: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C,AND ALL THAT APPLIES IN BOXD ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER 5?795 UNKNOWN A. TYPE OF 99 OTHER SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ ❑ 1 SAFE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE n 7 ALUMINUM ❑ g 100% METHANOL COMPATIBLE W/FRP MATERIAL ❑ �L✓,r/ (PrlmwyTmk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYO LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING �/eUNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES �JNNO_ ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 L WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC D.CORROSION 5 UNKNOWN ❑ 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A OTHER B. CONSTRUCTION A U i SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH U 5 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 CATHODIC PROTECTION U 5 UNKNOWN LA U 99 O9 F 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING 3 NiFASTRNL gg OTHER D. LEAK DETECTION ❑ ❑ MONITORING V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ e TANK TESTING ❑ 7 INTERSTITIAL MONITORING B1 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLEDWITH �'q� 1.ESTIM T D DATE LAST USE (MO/DAYIVR) SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 YES ❑ NO XY III THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT DATE APPLICANTS NAME (PRINTED 6 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FAC TANK L_J—L�IJ�J STATE I.D.# 0 PERMIT NUMBER PERMIT APPROVED SY/DATE PERMIT EXPIRATION DATE FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. 9--- 1 q_ 4 ( ` p- Foaoo eas