Laserfiche WebLink
0 'SOUR ; C <br /> STATE OF CAUFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMITAPPLICATION- FORM B <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED <br /> C? <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: -I;, 0L <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.# L9I/ B. MANUFACTURED BY: (( <br /> C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: <br /> II.TANKPONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. <br /> a REGULAR 3 DIESEL ❑ 6 AVIATION GAS <br /> A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL e. C. UNLEADED <br /> 2 PETROLEUM 60 EMPTY 1 0 PRODUCT 1bPREM1UM 4 GASAHOL <br /> ❑ 7 METHANOL <br /> ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ UNLEADED ❑ 5 JET FUEL <br /> 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 <br /> A. TYPE OF ❑ DOUBLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER E] 95 UNKNOWN <br /> SYSTEM 2 <br /> SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) El 99 OTHER <br /> 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B. TANK ff <br /> MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 1009% METHANOL COMPATIBLE W/FRP <br /> (Primary Tank) 0 9 BRONZE 0 10 GALVANIZED STEEL [—] 95 UNKNOWN ❑ 99 OTHER <br /> ❑ 1 RUBBER LINED 7-12 ALKYD LINING F-] 3 EPDXY LINING F--] 4 PHENOLIC LINING <br /> C.INTERIOR ❑ I -I 5 GLASS LINING 6 UNLINED 95 UNKNOWN E::] 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100'%METHANOL? YES_ NO_ <br /> D.CORROSION F-� 1 POLYETHYLENE WRAP W91 <br /> COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION F--] 5 CATHODIC PROTECTION NONE ❑95 UNKNOWN E:] 99 OTHER <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 SI GLE 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 4ARE ST 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 ?,GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION Elrl AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 MON STITIA [:] 99 OTHER <br /> V.TANK LEAK DETECTION <br /> ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING <br /> ❑ 6 TANK TESTING 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAY/YR 2.ESTIMATED SUBSTANCE REMAITY ININGF ��t C,(� GALLONS 3 WASNERT MATERIAL?TANK FILLED WITH YES [:] NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANT'S NAME DATE <br /> (PRINTED&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.# 7 ❑�l / <br /> PERMITNUMBER PERMIT APPROVED BY/DATE PERMIT (RATION l <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 /> FOR0034B-R4 <br />