Laserfiche WebLink
STATE OF CALIFORNIA '+ <br /> STATE WATER RESOURCES CONTROL BOARD s '' <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> MARK ONLY Q i NEW PERMIT O 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION 7 PERMANECLOSED ONSITE <br /> ONE REM O 2 INTERIM PERMIT O 4 AMENDED PERMIT a TEMPORARY TANK CLOSURE O 8 TANK REM D <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.0 -96 1 <br /> B. MANUFACTURED BY: /i <br /> C. DATE INSTALLED(MO/DAYNEAR) V..k D. TANK CAPACITY IN GALLONS: <br /> ILTANKCONTENTS IFA-11S MARKED,COMPLETE ITEM C. <br /> A. ❑ i MOTOR VEHICLE FUEL 4 OIL B. I UNLEADED <br /> C. E:l `REGULAR �3 DIESEL O 6 AVIATIONGAS <br /> ® 2 PETROLEUM 0 80 EMPTY �1 PRODUCT 0 IbPREMIUM 4 GASAHOL 0 7 METHANOL <br /> UNLEADED O 5 JETFUEL <br /> 3 CHEMICALPRODUCT 0 95 UNKNOWN 2 WASTE 0 2 LEADED 0 99 OTHER (DESCRIBE N ITEM D.BELOW) <br /> D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.# <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,8,AND C.AND ALL THAT APPLIES IN BOX D AND <br /> A. TYPE OF F--j 1 DOUBLE WALL F7 3 SINGLE WALL WITH EXTERIOR LINER Q 95 UNKNOWN <br /> SYSTEM Fs'2 SINGLE WALL Q 4 SECONDARY CONTAINMENT (VAULTED TANK) O 99 OTHER <br /> B. TANK O i BARE STEEL O 2 STAINLESS STEEL O 3 FIBERGLASS O 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL Q 5 CONCRETE 6 POLYVINYL CHLORIDE 0 7 AUJMINUM 8 100% METHANOL COMPATIBLE W/FRP <br /> (POmwyTmk) 9 BRONZE 10 GALVANIZED STEEL �9 UNKNOWN O 99 OTHER <br /> ❑ 1 RUBBER LINE 2 ALKYD LINING E] 3 EPDXY LINING O 4 PHENOLIC LINING <br /> C.INTERIOR 0 5 GLASS LINING O 6 UNLINED F-� 95 UNKNOWN O 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— <br /> D.CORROSION O 1 POLYETHYLENE WRAP 0 2 COATING O 3 VINYL WRAP 0 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 0 5 CATHODIC PROTECTION O 91 NONE &I 95 UNKNOWN O 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) 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 Alp SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH /®95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A U 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 W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION ACU>5 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION O 1 AUTOMATIC LINE LEAK DETECTOR E::] 2 LINE TIGHTNESS TESTING ❑ 3 <br /> MONITORING 99 OTHER <br /> V.TANK LEAK DETECTION <br /> O 1 VISUAL CHECK J;�,2 INVENTORY RECONCILIATION F7 3 VADOZE MONITORING O 4 AUTOMATIC TANK GAUGING O 5 GROUNDWATER MONITORING <br /> 6 TANK TESTING F-1 7 INTERSTITIAL MONITORING 91 NONE O 95 UNKNOWN O 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES O NO <br /> SUBSTANCE REMAINING GALLONS INERTMATERIAL? <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME DATE <br /> (PRINTED 4 SIGNATURE( <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY W6 TA <br /> STATE I.DA 117 1Loili 13 i <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE L <br /> THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FILE THIS FORM WITF" OCAL AGENCY IMPLEMENTING THE UNDERGROUND STS 1E TANK REGULATIONS <br /> BRM B (12-91) I FORMUS-R& <br />