BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

♦a 6a a^�. STATEOFCAUFORNA .� of 0 STATE WATER RESOURCES CONTROL BOARD w m� ;,p a UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B e , ., C�I��OP M��. COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVEDOf DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 7(o is _ 1-7 I; c L I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.0 B. MANUFACTURED BY: 6,eeiz _ C. DATE INSTALLED(MOIDAY/YEAR) e___ D. TANK CAPACITY IN GALLONS: II.TANKC ENTS IFA-11SMARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ IS REGULAR EGU R DIESEL ❑ 6 AVIATION GAS 4 GASAHOL [—] 2 PETROLEUM ❑ 30 EMPTY 1 PRODUCT ❑ IbUNLEADEO ❑ 5 JETFUEL ❑ 7 METHANOL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE M ITEM D. BELOW) D. IF(AA)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.i III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,ANDC.ANDALLTHATAPPLIES INBOXD A. TYPE OF [:] 1 LE WALL ❑ 3 SINGLE WALL WITH EXTERK)R LINER ❑ 95 UNKNOWN SYSTEM 2 SI WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER 1 BARE STEEL ❑ 2 STAINLESS STEEL F-] 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ S 100% METHANOL COMPATIBLE W/FRP MATERIAL ❑ 5 CONCRETE (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 96 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 AL LNNG ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL 7 VES_ NO_ O.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 C G ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 9B OTHER B. CONSTRUCTION A U 1 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 B 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 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 MONITORING ❑ 9g OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAP MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING 1 NONE ❑ B6 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERTMATERIAL7 YES ❑ NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED 6 SIGNATURE( LOCAL AGENCY USE ONLY THE STATELMNUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# C.4 7V� STATE I.D.# PERMIT NUMBER PERMIT APPROVED BY/DATE PERMITEXPIRA TE 3/f y 3} FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORO9M&R4 '✓C 1 �� V