Laserfiche WebLink
L.., eeoua e <br /> STATE OF CALIFORNIA � +� <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B ° <br /> B C�t,soPM�� <br /> COMPLETE A SEPARATE FORM FOR EAC K SYSTEM. <br /> MARK ONLY 0 1 NEW PERMIT 0 3 RENEWAL PERMIT Er5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ONSITE <br /> ONE ITEM 0 2 INTERIM PERMIT 0 4 AMENDED PERMIT 0 6 TEMPORARY TANK CLOSURE 0 8 TANK REMOVED / <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: /S 33 <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A OWNER'S TANK I.D.# B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAY/YEAR) l�rj D. TANK CAPACITY IN GALLONS: Ot)O <br /> II,TANK CONTENTS IFA-1 IS MARKED,COMPLFRE ITEM C. <br /> A 1 MOTOR VEHICLE FUEL 4 OIL B. 1aUNLEADED 3 DIESEL 6 AVIATIONGAS <br /> 0 2 PETROLEUM 0 80 EMPTY 0 1b PREMIUM 4 GASAHOL 0 7 METHANOL <br /> UNLEADED 0 5 JETFUEL <br /> 0 3 CHEMICAL PRODUCT 0 95 UNKNOWN iiT <br /> 0 2 LEADED 0 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: <br /> III. TANK CONSTRU N MARK ONE ITEM ONLY IN BOXES A.B,AND C,AND ALL THAT APPLIES IN BOX <br /> A. TYPE OF [Pr1 DOUBLE WALL 0 3 SINGLE WALL WITH EXTERIOR LINER 0 95 UNKNOWN <br /> SYSTEM 0 2 SINGLE WALL 0 4 SECONDARY CONTAINMENT (VAU DTANK) 0 99 OTHER <br /> B. TANK <br /> 0 1 BARE STEEL 0 2 STAINLESS STEEL 3 FIBERGLASS 0 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL F-1 5 CONCRETE 0 6 POLYVINYL CHLORIDE 0 7 ALUMINUM 0 8 100% METHANOL COMPATIBLE W/FRP <br /> (DrimafyTank) g BRON 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> 0 1 BEER LINED 0 2 ALKYD LINING 0 3 EPDXY LINING 0 4 PHENOLIC LINING <br /> C.INTERIOR 5 GLASS LINING 0 e UNLINED 0 % UNKNOWN 0 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— <br /> D.CORROSION O 1 POLYETHYLENE WRAP 0 2 COATING Q 3 VINYL WRAP EgIC11RIERGLASS REINFORCED PLASTIC <br /> PROTECTION 0 5 CATHODIC PROTECTION 0 91 NONE 0 95 UNKNOWN 0 % OTHER <br /> IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IFUNOERGROUND,BOTHIFAPPUCABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL A L A U 3 LINED TRENCH A U % UNKNOWN A U % OTHER <br /> C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A UiRG% PE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U % OTHER <br /> D. LEAK DETECTION 0 1 AUTOMATIC LINE LEAK DETEC"1R 0 2 LINE TIGHTNESS TESTING 0 3INTERSTITIAL O 99 OTHER <br /> MONITORING <br /> V.TANK LEAK DETECTION <br /> 1 VISUAL CHECK 0 2 INVENTORY RECONCILIATION 0 3 VAPOR MONITORING 4 AUTOMATIC TANK GAUGING 0 5 GROUND WATER MONITORING <br /> 0 6 TANK TESTING 0 7 INTERSTITIAL MONITORING 0 91 NONE 0 95 UNKNOWN 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES NO� <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL? <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME DATE <br /> (PRIMED 6 SIGNITUEE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK# <br /> STATE LDA <br /> PERMIT NUMBER PERMIT APPROVED SY/DATE PERMIT EXPIRATION DATE <br /> FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> �1 FORp B-RI <br />