Laserfiche WebLink
pGso"ICes c <br /> STATE OF CALIFORNIA P <br /> STATE WATER RESOURCES CONTROL BOARD 3G. <br /> IT LI TI - F w� � o <br /> ra o <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY F-� 1 NEW PERMIT 3 RENEWAL PERMIT F-1 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ONSITE <br /> ONE ITEM F-] 2 INTERIM PERMIT n 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: <br /> I. TANK DESCRIPTION C MPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.# B. MANUFACTURED BY: G, <br /> C. DATE INSTALLED(MO/DAY/YEAR) /cm <br /> L D. TANK CAPACITY IN GALLONS: <br /> II, CONTENTSIFA-1 IS MARKED,COMPLETE ITEM C. <br /> A. a 1 MOTOR VEHICLE FUEL 4 OIL B. G. la REGULAR 3 DIESEL 6 AVIATION GAS <br /> 2 PETROLEUM Ej 80 EMPTY E::] 1 PRODUCT lb PREMIDUM ED 4 GASAHOL ❑ <br /> 7 METHANOL <br /> UNLEADED 5 JET FUEL <br /> 3 CHEMICAL PRODUCT E�] 95 UNKNOWN FX2 WASTE 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED J ! 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 Al e- G P <br /> A. TYPE OF 1 DOUBLE WALL F--] 3 SINGLE WALL WITH EXTERIOR LINER E:l 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) F--] 99 OTHER <br /> B. TANK 1 BARE STEEL 2 STAINLESS STEEL F-] 3 FIBERGLASS Ej 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL 0 5 CONCRETE F POLYVINYL CHLORIDE F--] 7 ALUMINUM 0 8 100°/ METHANOL COMPATIBLE W/FRP <br /> (Primary Tank) 9 BRONZE E:l 10 GALVANIZED STEEL E 95 UNKNOWN a 99 OTHER <br /> 1 RUBBER LINED F72 ALKYD LINING � 3 EPDXY LINING F-] 4 PHENOLIC LINING <br /> LINING <br /> C.INTERIOR E] 5 GLASS LINING NY 6 UNLINED F-] 95 UNKNOWN 99 OTHER <br /> IS LINING MATERIAL COMPATIBLE WI H 100%METHANOL? YES— NO— <br /> D.CORROSION C� 1 POLYETHYLENE WRAP a 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION l--J�5 CATHODIC PROTECTION F-] 91 NONE D 95 UNKNOWN F-] 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A 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 AV 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 A U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING 3 INTERSTITIA <br /> MONITORING ❑ 99 OTHER <br /> V.TANK LEAK DETECTION <br /> 0 1 VISUAL CHECK 2 INVENTORY RECONCILIATION F-] 3 VADOZE MONITORING a 4 AUTOMATIC TANK GAUGING a 5 GROUND WATER MONITORING <br /> 6 TANK TESTING 7 INTERSTITIAL MONITORING F-] 91 NONE 95 UNKNOWN 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAY/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 /> APPLICANTS NAME DATE <br /> (PRINTED a 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.# I I 1 a 2 <br /> PERMIT NUMBER ERM IT APPROVED BY/DATE PERMIT EXPIRATION DATE <br /> FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> a0 FOROIX#B-RS <br />