Laserfiche WebLink
STATE OF CALIFORNIA ...... ` <br /> STATE WATER RESOURCES CONTROL BOARD s g <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B �o " <br /> � /� COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM ��`"°"�� <br /> MARK ONLY 1 NEW PERMIT a 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ONSITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED D <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: <br /> 1. 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 � D. TANK CAPACITY IN GALLONS: S 570 <br /> Y D <br /> II.TANK CONTENTS IFA-tISMARKED,COMPLETE ITEM C. la REGULAR <br /> REGULAR 3 DIESEL <br /> A (x t MOTOR VEHICLE FUEL 4 OIL B. C. UNLEADED a 6 AVIATION GAS <br /> 2 PETROLEUM 80 EMPTY 1 PRODUCT a tb PREMIUM 4 GASAHOL 7 METHANOL <br /> UNLEADED � 5 JET FUEL <br /> 03 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE 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.x: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B.AND C.AND ALL THAT APPLIES IN BOX D <br /> A. TYPE OF 1 DOUBLE WALL F7 3 SINGLE WALL WITH EXTERIOR LINER E:] 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALL a 4 SECONDARY CONTAINMENT (VAULTED TANK) O 99 OTHER <br /> I BARE STEEL F-12 STAINLESS STEEL 0 3 FIBERGLASS a 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B. TANK <br /> MATERIAL 0 5 CONCRETE E:] 6 POLYVINYL CHLORIDE 0 7 ALUMINUM li] 8 10076 METHANOL COMPATIBLE W/FRP <br /> (PrimaryTank) 9 BRONZE 10 GALVANIZED STEEL Q 95 UNKNOWN 0 99 OTHER <br /> a 1 RUBBER LINED 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR O 5 GLASS LINING x; 6 UNLINED 95 UNKNOWN 99 OTHER <br /> LINING !` % <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_yNO_ <br /> D.CORROSION O 1 POLYETHYLENE WRAP 2 COATING a 3 VINYL WRAP a 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION 91 NONE Q 95 UNKNOWN 0 99 OTHER <br /> IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A,40 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A U BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U d FIBERGLASS PIPE <br /> CORROSION A 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 99 OTHER <br /> INTERSTITIAL <br /> D. LEAK DETECTION O <br /> 1 AUTOMATIC LINE LEAK DETEC nil [:] 2 LINE TIGHTNESS TESTING Q 3 MONITORING Q 99 OTHER <br /> V.TANK LEAK DETECTION <br /> a t VISUAL CHECK 2 INVENTORY RECONCILIATION 3 VAPOR MONITORING 4 AUTOMATIC TANK GAUGING O 5 GROUND WATER MONITORING <br /> 6 TANK TESTING 7 INTERSTITIAL MONITORING 91 NONE Q 95 UNKNOWN O 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USE MO AY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY.AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> DATE <br /> APPLICANTS NAME <br /> (PRINTED 8 SIGNATURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK# <br /> STATE I.D.# <br /> PERMIT NUMBER PERMIT APPROVED BY/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 /> D f I — q-3 <br /> � FORama�ru <br />