BILLING 1997 - 2005 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD ry UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B c, COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑; 3 RENEWAL PERMIT 5 CHANGE OF INFORMATICN ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT C! 4 AMENDED PERMIT 5 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK 1.D.f 2 I B. MANUFACTURED BY: �S C. DATE INSTALLED(MOIDAY/YEAR) , 4U -1 D. TANK CAPACITY IN GALLONS: 1'z 7\U 0 II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. lJ A. [K 1 MOTOR VEHICLE FUEL a 4 OIL B. j C 1a REGULAR UNLEADED 3 DIESEL 6 AVIATICNGAS ❑ 2 PETROLEUM ❑ 80 EMPTY i 1 PRODUCT I V 15 PREWUM CNLEACED 4 GASAHOL ❑ 7 METHANOL .U� 1c MIDGRADE UNLEADED 5 JET FUEL ❑ 8 M65 3 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE 2 LEADED 99 OTHER;CESCRIBE IN ITEM D.5ELO',1 0. 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.S.AND C,AND ALL HAT APPLES IN BOX D AND E A. TYPE OF Xl I 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 3 FIBERGLASS ❑ 4 STEEL CLAD W1 FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100916 METHANOL COMPATIBLE WlFRP (PrlmaryTank) ❑ 9 BRONZE O 10 GALVANIZED STEEL L I 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING I❑ 3 EPDXY LINING 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ® 6 UNLINED —I 95 UNKNOWN 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES-X- NO_ D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING 3 VINYL WRAP ; 4 PISERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHOOICPP07ECTION ❑ 91 NONE 95 UNKNOWN OTHER E.SPILL AND OVERFILL,BIC. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES�_ NO STRIKER PLATE vES X NO D:SPENSER 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 U 1 SINGLE WALL A&2 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 STEL A U 3 POLYVINYL CHLORIDE(PVC)Ar_U/4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL WI COATING A U B 100916 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 ®I UECKWCAL LINE LEAK O 2 UNE TIWNESS 0 3 CcfmP,'IOUS INTERSr1UL ❑4 ELECACNIC USE 5 AUrOMATIC PUMP — 99 OT7iER DETECOR TESTING mowc;:INO LJK Cha=R ix SHIJMrolm l— V.TANK LEAK DETECTION '-1 1 VISUAL CHECK 2 MANUAL INVENTORY r 3 VADOZE J 4 AUTOMATIC TANK I1- 5 GROUND WATER ❑ 6 ANNUAL TANK RECONCILIATION a MONITORING GAUGING MONITORING TESTING (� 7 CONTINUOUS INTERSTITIAL 9 WEEKLY MANUAL �❑ 10 MONTHLY TANK 95 UNKNOWN 99 OTHER MONITORING B SIR TANK GAUGING TESTING VI.TANK CLOSURE INFORMATION (PERMANENT CLOSURE IN-PLACE) I.ESTIMATED CATE LAST USED(MO/OAYNR) 2.ESTIMATED CUANTITY CF 3.WAS TANK F,LLED bVITH YES ::] NO — SUBSTANCE REMAINING GALLONS INEPT I:ATERIAL? --- THIS FORM NAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE ANO CORRECT TANK OWNER'S NAME DATE (PRINTED 8 SIGNATURE) \\\ (� -2 LOCAL AGENCY USE ONLY THE STATE`I.D.NUMBER IS COMPOSED OF THE FOUR MBERSABELOW COUNTY a JURISDICTION a F CILI7Y+ TANK s STATE I.D.# PERMIT.1T NUN.BER I PERMIT APPROVED BY/CATE PERMIT EXPIRATION DATE 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 SE -CCOMPANIED BY A PLOT PLAN. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (6951