BILLING 1997 - 2005 - Laserfiche WebLink

Home Browse Search

tspunccs STATE OF CALIFORNIA cOa, STATE WATER RESOURCES CONTROL BOARD V m UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B o •C�I.i OA H� COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ITE ONE ITEM ❑ 2 INTERIM PERMIT 7] 4 AMENDED PERMIT ED TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED 1 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: fi ,Co /►� e L (p 3 J' �tslq - I I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# ' B. MANUFACTURED BY: x E C. DATE INSTALLED(MO/DAY/YEAR) 'jZ'l q7 D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. q � 1 MOTOR VEHICLE FUEL F-1 4 OIL B. C ❑ 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL is MIOGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 17 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM 0.BELOW) 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 ALL THAT APPLIES IN BOX D AND E A. TYPE OF j< 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL K 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLEW/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ® 99 OTHER—� � COATING IS LINING 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,BtC. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL P EVENTION EQUIPMENT INSTALLED(YEAR) 22 7 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 PRESSURE A U 3 GRAVITY 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U i SINGLE WALL A DOUBLE WALL A U 3 LINED TRENCH A U 95 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® 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 MECHANICAL LINE LEAK 2 LINE T 3 CONTINUOUS INTERSTITIAL 4 ELECTRONIC LINE 5 AUTOMATIC PUMP gg OTHER D. LEAK DETECTION DETECTOR [:] TESTINGIGHTNESS MONITORING ❑ LEAK DETECTOR SHUTDOWN ❑ V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK E] 2 MANUAL INVENTORECONCILIATION RY ❑ 3 MONITORING VADOZE ❑ 4 GAUGING AUTOMATIC TANK E::] 5 MON TORINGGROUND WATER E:] 6 TESTINGANNUAL �7 MONITORING INTERSTITIAL ❑ 8 SIR ❑ 9 WEEK LY MANUAL ❑10 T ONTHLY TANK El 95 UNKNOWN [:199 OTHER NG VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) p� A- 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME `A�`L/y J � �� DATE (PRINTED 8 SIGNATURE) �/y{�{'�, / v LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY#1 TANK# 00 1 STATE I.D.# m PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE I THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT P' FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THF"-"ERGROUND STORAGE TANKREGULATIONS^ FORM B (6.95) 1 +� I w