Laserfiche WebLink
STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY F 1 NEW PERMIT 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED DNS <br /> ONE ITEM F7 2 INTERIM PERMIT 4 AMENDED PERMIT O 6 TEMPORARY TANK CLOSURE FV8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ni <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.# 7a. B. MANUFACTURED BY: ( } <br /> C. DATE INSTALLED(MO/DAY/YEAR) i D. TANK CAPACITY IN GALLONS: <br /> ILTANKCONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. <br /> 1a REGULAR 3 DIESEL <br /> A. 1 MOTOR VEHICLE FUEL 4 OIL B.: C• UNLEADED 6 AVIATION GAS <br /> 2 PETROLEUM 80 EMPTY 1 PRODUCTE]"', <br /> 1b PREMIUM 4 JET <br /> FUE L 7 METHANOL <br /> u UNLEADED 5 JET FUEL <br /> 0 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 C.A.S.# <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C,AND ALL THAT APPLIES IN BOX D AND E <br /> A. TYPE OF F-] 1 DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER D 95 UNKNOWN <br /> SYSTEM V2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) F-] 99 OTHER <br /> B. TANK 1 BARE STEEL F-] 2 STAINLESS STEEL F7 3 FIBERGLASS D 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL F] 5 CONCRETE F7 6 POLYVINYL CHLORIDE 7 7 ALUMINUM E� 8 100°/6 METHANOL COMPATIBLE W/FRP <br /> (PrimaryTank) 09 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> a i RUBBER LINED 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR F--] 5 GLASS LINING E::] 6 UNLINED '95 UNKNOWN 99 OTHER <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO <br /> D.CORROSION ❑ 1 POLYETHYLENE WRAP F--] 2 COATING VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION F-� 5 CATHODIC PROTECTION E::] 91 NONE ��95UNKNOWN E�:] 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) kOa OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A It 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 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 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 Af U:95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION [:] 1 AUTOMATIC LINE LEAK DETECTOR � 2 LINE TIGHTNESS TESTING 3 <br /> INTE <br /> S AL 99 OTHER <br /> V.TANK LEAK DETECTION <br /> 1 VISUAL CHECK F-1 2 INVENTORY RECONCILIATION 3 VADOZE MONITORING 0 4 AUTOMATIC TANK GAUGING 5 GROUND WATER MONITORING <br /> Fo 6 TANK TESTING 0 7 INTERSTITIAL MONITORING 91 NONE 95 UNKNOWN 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1. STIMATED DATE LAT SED(MO/DAY R 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES [p--oNO <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL? <br /> THIS FORM HAS BEEN COMPLETEDENALL OF,pqpJU Y,A TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTSNAME DAT <br /> IPAI T D GN Ia col <br /> I <br /> LOCAL AGENCY USE ONLY THE ST E I.D.NUMBEigOMPOSFD OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK# Ar , ol <br /> STATE I.D.# N <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE <br /> THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FOAM B (12-91) FOROD34XRS <br />