BILLING - Laserfiche WebLink

Home Browse Search

0 0 STATE OF CALIFORNIA �•o"+«, STATE WATER RESOURCES CONTROL BOARD " �' UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B �d� . . o 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 REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ®' 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: MAN f-.(((A IA Sly, 6 ew Vl S S4U� I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNER'S TANK I.D.p I / B. MANUFACTURED BY: u N C. DATE INSTALLED(MO/DAYNEAR) U N L(. D. TANK CAPACITY IN GALLONS: I �� II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. 1e REGUL4R UMEADED 3 DIESEL 6 AVIATION GAS A, [251 MOTOR VEHICLE FUEL r74 OIL B. C. E)F-12 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT ❑ 16 PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 1c MIDGRADE UNLEADED ❑ 5 JETFUEL 8 M85 ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.p: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C.AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR UNER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ® 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK FWJ 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 (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC UNING LINING OR ❑ 5 GLASS LINING I�S� 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS UNING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,BSC. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES NO_ STRIKER PLATE YES NO DISPENSER CONTAINMENT YES_ NO 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 U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A(V 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A i)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 8 100% 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 U 1 NECHANICAL NE OF 2 UNE TWXTNEEp 3 CWINU INTER nra U:CnICNIC NE UTOW71C PUAW ❑ U OErECTOR ❑ rE3nNG ❑ MGMTGRING ❑4 EL K DETECTOR ❑5 AENlr w ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL RECONCILIIATIONORY F] 3 MONIITORING ❑ 4 GAUGING VAOZEAUTOMATIC TANK ❑ 5 MOON TORINGTER ❑e TESTINGNUAL TANK ❑ 7 MONITORING CONTMOUSINTERSTITIAL ❑ 8 SIR ❑ 9 TANK LY MANUAL ❑10 MOTESTINGHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OFLL3.WAS TANK FILLED WITH SUBSTANCE REMAINING Z: GAONS INERT MATERIAL? YES ❑ NO ❑ THIS FORM HAS BEEN COMPLETED UNDER PEN TY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK-BYMIR'S NAME. ,1 GATE (PAINTED&SIGNATORE) 16c I// LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY#7 8 TANK#00 T STATE I.D:# m g — n1;? 1.;2 1-:M v✓i./QL PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLIC,,��jTTIIION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FgMW MUST BE COMPLETED FOR INSTALLATIONS'THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THERFFIGROUND STORAGE TANK REGULATIONS FORM B (6-95)