Laserfiche WebLink
`q�u-cP9 <br /> STATE OF CALIFORNIA `' <br /> STATE WATER RESOURCES CONTROL BOARD . ' <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br /> .i1• . <br /> COMPLETE A SEPARATE FORM FOR YCH TANK SYSTEM. <br /> MARK'ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ® 7 PERMANE EO ON E <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE a 8 TANK MOV <br /> OBA OR FACILITY NAME WHERE TANK IS INSTALLED: A2Lo F-AC.,. 140. ®r�,.,-l4a n <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.s i-ui LL_s IZ B. MANUFACTURED BY: <br /> U 1,445+-LO W),1 <br /> C. DATE INSTALLED(MOIDAY/YEAR) ®S f_/z.co I 0. TANK CAPACITY IN GALLONS: 44-000 <br /> II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. <br /> A. LYJ MOTOR VEHICLE FUEL d OIL B. C. L,f�IaUNLEA ED 3 DIESEL 6 AVIATION GAS <br /> 2 PETROLEUM � 80 EMPTY (—tia GASAHOLt PRODUCT (-'� lb PREMIUM 7 METHANOL <br /> ❑ 3 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE ^-� 2 LEADED 5 JET FUEL <br /> 99 OTHER (DESCRIBE IN ITEM 0. BELOW) <br /> D: IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.a <br /> Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.S.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 Ei^'2 SINGLE WALL ® 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER <br /> B. TANK C„ 1 BARE STEEL 2 STAINLESS STEEL ❑ 3 FIBERGLASS ® d STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL Q 5 CONCRETE ® 6 POLYVINYL CHLORIDE 7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP <br /> (PrimaryTank) 9 BRONZE 10 GALVANIZED STEEL n 95 UNKNOWN 99 OTHER <br /> 1 RUBBER LINED 2 ALKYD LINING ❑ 3 EPDXY LINING d PHENOLIC LINING <br /> C.INTERIOR �1 <br /> LINING 5 GLASS LINING �6 UNLINED 95 UNKNOWN 99 OTHER <br /> l_J <br /> IS UNING MATERIAL COMPATIBLE WITH 1001/.METHANOL? YES_ NO_ <br /> D.CORROSION ❑ 1 POLYETHYLENE WRAP 2 COATING = 3 VINYL WRAP d FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION Q 91 NONE j�45 UNKNOWN 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> IV.PIPING INFORMATION CIRCLE A IFA80VEGROUNDOR U IF UNDERGROUND,80TH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A&2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION AID 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND Atli)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'ANCOATING A U 8 100% METHANOL COMPATIBLE WIFRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION v / AUTOMATIC LINE LEAK DETECTOR � LINE TIGHTNESS TESTING 3 99 OTHER <br /> := <br /> V.TANK LEAK DETECTION <br /> C211 VISUAL CHECK 2 INVENTORY RECONCILIATION C:] 3 VAOOZE MONITORING ® 4 AUTOMATIC TANK GAUGING F7 5 GROUND WATER MONITCRING <br /> =� TANK TESTING ❑ 7 INTERSTITIAL MONITORING 91 NONE 95 UNKNOWN 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MC/DAY/YR) ( 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES NO <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL? ' <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST MY KNOWLEDGE. 1S TRUE AND CORRECT <br /> APPLICANTS NAME DATE <br /> iPRINTED&SIGNATURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR AMBERS BELOW <br /> STATE 1.014 o COUNTY# JURISDICTION x FACILfTY x TANK N <br /> ., ; I I I %' ! � / 2 171(, I ; (jl,�•� <br /> PERMIT NUMBER ' PERMIT APPROVED BY/DATE PERMIT EXPIRATION CATE <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 /> FOR00118•.75 <br /> r <br />