BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

ul • • a STATE OF CALIFORNIASTATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B CO LETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ e TANK REMOVED O/ DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I. D. a i '% S. MANUFACTURED BY: C. DATE INSTALLED (MO/DAY/YEAR) / D. TANK CAPACITY IN GALLONS' .EyN I uv 10 IFA -115 MARKED, COMPLETE ITEM C A. LV1 MOTOR VEHICLE FUEL ❑ 4 OIL ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED g, C 1a REGULAR UNLEADED 1 PRODUCT lb PREMIUM UNLEADED 2 WASTE "''ffff"'' ❑ ❑ 2 LEADED III. IAINN L,LJNnJKUL.JI1JN .neovnn1v 11.11—..--,.....— -....._..."... _.._____ 3 DIESEL ❑ 6 AVIATIONGAS 4 GASAHOL ❑ METHANOL 5 JET FUEL 99 OTHER (DESCRIBE IN ITEM D. BELOV C.A.S.#: A. TYPE OF❑ SYSTEM Y DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN p U 2 INGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK 1 BARE STEEL Elor❑ A U 2 STAINLESS STEEL 3 FIBERGLASS❑ ❑ 4 STEEL CIAO W/ FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Prlmaly Tank) ❑ 9 BRONZE ❑ /0 GALVANIZED STEEL 95 UNKNOWN 99 OTHER C. N E:]1 RUBBER LINED E:]5 GLASS LINING ❑ 2 ALKYD LINING EPDXY LINING 4 PHENOLIC LINING LININGINING IS LINING MATERIAL COMPATIBLE WITH 6 UNLINED 95 UNKNOWW IW% 99 OTHER METHANOL? YES— NO"k4dw-e\ D. CORROSION ❑ 1 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) Ill nlnuln ul�r,....—.... A. SYSTEM TYPE A U 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 CORROSION PROTECTION A U A U A U BARE STEEL 5 ALUMINUM GALVANIZED STEEL A U A U A U 2 STAINLESS STEEL A U 6 CONCRETEp U 10 CATHOD PROTECTION 3 POLYVINYL CHLORIDE (PVC) A U 7 STEELW/COATING A U A U 95 UNKNOWN A U 4 FIBERGLASS PIPE 8 100% METHANOL COMPATIBLEW/FRP 99 OTHER D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR I V 2 LINE TIGHTNESS TESTING ❑ 3 v T.uv 1 MONROPING ❑ BE OTHER LV I IVI\ ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING 4 AUTOMATIC TAN UGI(JG ❑ 5 GROUNDWATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN a h ❑ 99 OTHER /. ESTIMATED DATE LAST USED (MO/DAY/YR) I 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES ❑ NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY AND Tn Tur P=0T nc ..1.1..,.,1.,,.,, ,,,Rvrr�c✓vc, /O TRUE AND Cub APPLICANTS NAME (PRINTED 8 SIGNATURE) DATE LOCAL AGENCY VINLT IME STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# Fecal . STATE I.D.# PERMIT TANK# DATE FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION - FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. 0 0 7ECT