Laserfiche WebLink
STATE OF CAUFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD i4 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B y <br /> 0 <br /> COMPLETE A SEPARATE FORM FOR ACH TANK SYSTEM. ��` ""'• <br /> MARK ONLY 1 NEW PERMIT a 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION Q 7 PERMANEN Op)SITE <br /> ONE ITEM 2 INTERIM PERMIT O 4 AMENDED PERMIT 8 TEMPORARY TANK CLOSURE a 8 TANK R <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: '20j <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.# D(� I B. MANUFACTURED BY: L; <br /> C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: �O C <br /> 11.TANK CONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. <br /> 1 MOTOR VEHICLE FUEL 4 OIL g, C 1�1 to REGULAR 3 DIESEL <br /> ;A a g AVIATION GAS <br /> A. UNLEADED <br /> O 2 PETROLEUM 80 EMPTY 1 PRODUCTlb PREMIUM H 4 GASAHOL 7 METHANOL <br /> O <br /> a 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.III: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.8,AND C.AND ALL THAT APPLIES IN BOX D AND E <br /> A. TYPE OF 1 DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER <br /> B. TANK LJ 1 BARE STEEL O 2 STAINLESS STEEL 3 FIBERGLASS j 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL 5 CONCRETE 6 POLYVINYL CHLORIDE 7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP <br /> (PrimaryTank) 9 BRONZE C 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> 1 RUBBER LINED 2 ALKYD LINING (� 3 EPDXY LINING = 4 PHENOLIC LINING <br /> C.IN <br /> LINING L 11 5 GLASS LINING 6 UNLINED 95 UNKNOWN ❑ 99 OTHER <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO <br /> D.CORROSION 1 POLYETHYLENE WRAP 2 COATING 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION 9/ NONE 95 UNKNOWN 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) y�S 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 AU 2 RESSURE A U 3 GRAVITY <br /> A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL A jofof_�OUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A U i BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A 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 <br /> A U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING MONfio.ING U 99 OTHER <br /> V.TANK LEAK DETECTION <br /> 71 VISUAL CHECK 2 INVENTORY RECONCILIATION CI 3 VADOZE MONITORING A 4 AUTOMATIC TANK GAUGING 5 GROUND WATER MONITORING <br /> (� 6 TANK TESTING 7 INTERSTITIAL MONITORING ^ 91 NONE El 95 UNKNOWN a 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MOOAY/YR) 2.ESTIMATED QUANTITY OF I 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES [::] NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENAL OF PE Y,A TO N ST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME DATE <br /> (PRINTED&SIGNATURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED FOUR NUMBERS BEL <br /> COUNTY# JURISDICTION# FACILITY# TANK#(-05- <br /> STATE I.D.# 7 Z ? <br /> PERMIT NUMBER PERMIT APPROVEDBY/DATE PERMIT EXPIRATION DATE f i <br /> � r jec <br /> IAS <br /> THIS FORM MUST BE ACCOMPANIED SY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. "C <br /> FILE THIS FORM WITH T•ff AL AGENCY IMPLEMENTING THE UNDERGROUND STO JOTANK REGULATIONS . <br /> FORM 8 (12-911 <br /> ,6`'031 FORoaus. <br />