BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

a 0 STATE OF CALIFORNIA �s STATE WATER RESOURCES CONTROL BOARD�� a'•f.® 5 UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B c' LETE A SEPARATE FORM FORE H TANK SYSTEM. °.r oo'U MARK ONLY ❑ i NEW PERMITIt-3RENEWAL PERMIT [ErS CHANGE OF INFORMATION 7 PERMANENTLY LOS ITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I. D.# lei a g, B. MANUFACTURED BY: h C. DATE INSTALLED (MOIDAYNEAR) 19 3-7- ❑ 80 EMPTY 1 D. TANK CAPACITY IN GALLONS: / D� i! Z-� II. TANK CCATFNTS IFA.II.RMARKFnmuaIFTFITFMr` A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL g, C. ❑ 1a REGUL S UNLEAD❑ h 3 DIESEL ❑ 8 AVIATION GAS 2 PETROLEUM ❑ 80 EMPTY 1 Pfl)DUCT 1b PREMIUM L_f 4 GASAHOL [:]7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE UNLEADED ❑ 2 LEADED ❑ 7 ALUMINUM 5 JETFUEL (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER 99 OTHER (DESCRIBE IN ITEM O. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED ❑ 2 ALKYD LINING ❑ EPDXY LINING ❑ 4 PHENOLIC LINING III. TANK CONSTRUCTION MARKnNFIWMnNI V INF(1YFSG o Aunc suns Tu.T.eei i« . e A. TYPE OF ❑ DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 INGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEOTANK) ❑ 99 OTHER - B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W1 FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER CORROSION ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING ❑ 8 UNLINED 95 UNKNOW ❑ 99 OTHER GALVANIZED STEEL IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL 7 YES— NO /,(jyZdCjT,QY1yY� D. CORROSION ❑ I POLYETHYLENE WRAP ❑ COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE 95 UNKNOWN ❑ 99 OTHER E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF IINOFRGROUNn RnT w... Icsm F A. SYSTEM TYPE A II 1 SUCTION p U PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 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 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC)A U 4 FIBERGLASS PIPE CORROSION A U ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U GALVANIZED STEEL A U 10 CATHOD PROTECTION A U 95 UNKNOWN A U 99 OTHER . LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING ❑ 3 -1 99 OTHER MOWMRING I. I ANY, LEAK UE I EO 1 ION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING 4 AUTOMATIC TANa ?4UGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN 1U /ph ❑ 0 OTHER VI. TANK CLOSURE INFORMATION 1. ESTIMATED DATE LAST USED (MOIOAY/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES ❑ NO ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE. IS TRUE AND CORRFCT APPLICANT'S NAME (PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OFTHE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # TANK # STATE I.D.# PERMIT NUMBER PERMIT APPROVED BY/DATE �-�-�-I PERMIT EXPIRATION DATE FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORMA, UNLESS A CURRENT FORMA HAS BEEN FILED. • • Idvi L