BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

� 'ty Un ( Co STATEOFCAUFORMA \f c� y� STATE WATER RESOURCES CONTROL BOARD ' a UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM El >o `� o COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. °�r"°"",� MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ANGE OF INFORMATION 7 E NTLY CLO IT ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE K REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: a V70 64,,L} I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.i B. MANUFACTURED BY: p C. DATE INSTALLED(MO/DAY/VEAfl) D. TANK CAPACITY IN GALLONS: �(�!/ 11.TANK CONTENTS IFA-11SMARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1a REGULAR n 3 DIESEL ❑ 6 AVIATION GAS LH�J 4 GASAHOL ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT lb PRE&IUMUNL ❑ 5 JET FUEL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE O 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D.BELOW) 0. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.i III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOX A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER E_] 95 UNKNOWN SYSTEM Foi- f GLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER ��STEEL ❑ 2 STAINLESS STEEL F73 FIBERGLASS E::] 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE e POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED WN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL7 YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE R 6 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A* SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A CA SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U S 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODICP CTION 5 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ ' AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING Q 3 MONRORING ❑ BB OTHER V.TANK LEAK DETECTION ❑ 1 VIS HECK 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING TANKTESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO SUBSTANCE REMAINING GALLONS INERTMATERIAL7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE IPBINTED86iG.ATUREI LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# p S 5 0 3 {2e1 i7 PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE r /� 7 FORM B 19-90) THIS FORM GRIST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. �a' 1 W FOIIOaMBR{