Laserfiche WebLink
' � ! 'tyo Y•ceg <br /> STATE OF CALIFORNIA �P R• co <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B �:� �,,, 10 <br /> h; <br /> ' C4(fON N•. <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY [] 1 NEW PERMIT <br /> E:] 3 RENEWAL PER 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE <br /> ONE ITEM El2 INTERIM PERMIT E] 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED �. <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED- IhCll _ U <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> B. MANUFACTURED BY: <br /> A. OWNER'S TANK I.D. n �00 <br /> 77- <br /> C. DATE INSTALLED(MO/DAY/YEAR) <br /> D. TANK CAPACITY IN GALLONS: <br /> IL TANK CONTENTS IFA-11SMARKED,COMPLETE ITEM C. la REGULAR ❑ 3 DIESEL ❑ 6 AVIATIONGAS <br /> 4 OIL B. C UNLEADED <br /> A 1 MOTOR VEHICLE FUEL ❑ ❑ 4 GASAHOL PREMIUM 7 METHANOL <br /> ❑ 2 PETROLEUM <br /> ❑ 80 EMPTY �1 PRODUCT ❑ 1bUNLEADED ❑ 5 JET FUEL <br /> ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED <br /> C.A.S.#: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX D <br /> 1 DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER <br /> SYSTEM '� ❑ 95 UNKNOWN <br /> A. TYPE OF V2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER <br /> ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B. TANK 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 100% METHANOL COMPATIBLE W/FRP <br /> MATERIAL ❑ <br /> (Primary Tank) E] 9 BRONZE ❑ 10 GALVANIZED STEEL if"95 UNKNOWN ❑ 99 OTHER <br /> ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING F7 J3 EPDXY LINING ❑ 4 PHENOLIC LINING <br /> C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED I.#X 95 UNKNOWN ❑ 99 OTHER <br /> LINING YE <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO <br /> ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC <br /> D.CORROSIONUNKNOWN ❑ 99 OTHER <br /> PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE e 5 <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE <br /> TEM TYPE A U �1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> A. SYS <br /> B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE p U 7 STEEL W/ A U 8 10('/ METHANOL COMPATIBLEW/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A�95 UNKNOWN A U 99 OTHER <br /> 3 INTERSTITIAL ❑ 99 OTHER <br /> D. LEAK DETECTION [:11 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ MONITORING <br /> V.TANK LEAK DETECTION <br /> ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING <br /> J ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER <br /> VI.TANK CLOSURE INFORMATION 3.W�TANK <br /> D WITH2.ESTIMATED QUANTITY OF YES ❑ NO❑R) SUBSTANCE REMAINING GALLONS <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, <br /> IS TRUE AND CORRECT <br /> DATE <br /> APPLICANTS NAME <br /> (PRINTED S SIGNATUREI <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW L / <br /> COUNTY# JURISDICTION# FACILITY#3-fl& TANK# <br /> STATE I.D.# <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE <br /> FORM B (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM"�� <br /> UNLETA CURRENT FORM A HAS BEEN FILFQ. <br /> O� � FOR0¢34B.R4 <br /> JP) IB �� <br />