BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD iym� UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B e I COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT O 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: A3 15 ` e C• I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN Q �b ply A OWNER'S TANK I.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNFAR) 6612AD. TANK CAPACITY IN GALLONS: s II.TANK CONTENTS IF Al IS MARKED,COMPLETE ITEM C. A ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. to REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY ��Qi PRODUCT ❑ 19 PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL �\ ❑ 1t MIDGRADE UNLEADED ❑ 5 JETFUEL ❑ 8 M85 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN REM D.BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OFSUBSTANCE STOREDz6e-lkC.AS.a: D a III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM I�� SINGLE WALL F-14 SINGLE WALL IN A VAULT E] 99 OTHER B. TANK J�-�I BARE STEEL F-12 STAINLESS STEEL F-13 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL !❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PHmary Tok) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING �8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ Nox D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION 5 CATHODIC PROTECTION 1 NONE 95 UNKNOWN 99 OTHER E.SPILL AND OVERFILL,BIC. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE VES ' NO_ STRIKER PLATE VES NO DISPENSER CONTAINMENT YES_ NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE AU 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLEPIPING A U 99 OTHER B. CONSTRUCTION &U21 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑1 MEa M MELFAK ❑2 M TED W ❑3 colRUMaB WfER5T ❑4 FJE MM LINE ❑s AuroMAnc Rar 9s OTHER OETEmm TESTING MONTORRm [FAR DETECTOR 9NTRGWN V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCAL ILIATION CILIATIONORY ❑ 3 MONITORING ❑ 4 GAUGING AUTOMATIC TANK ❑ 5 GROUND MONITORING TER ❑ 6 TESTINGTANK ❑ 7 CCOONTINNU U INTERSTITIAL ❑ONITORINGB SIR ❑ 9 WEEKLY MANUAL ❑10 MONTHLY TANK NG 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DA ST=R) 2.ESTIMATED OUANRTY O 3.WAS TANK FILLED WITH YES ❑ N SUBSTANCE REMAININ G NS I INERT MATERIAL? Nl THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJU Y,AND TO BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTED d MGNATURE) p� LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW jee.c--T J) �0, COUNTY 6 JURISDICTION R FACILITY a TANK M pv STATE I.Dl 310 = PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT E%PIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FORM C MUST BE COMPLETED MRINSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PI' 9LE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE I �RGROUND STORAGE TANK REGULATIONS FORM B (6-95) / I 3 !T f S,C`�� T ID��D I I FORM316R7