BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

`64ou^C49 C P pi's STATE OF CALIFORNIA o STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B • �111pw M♦ COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE ON E 14 ONE ITEM n 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED DBA OR FACILITY NAME WHERE TANK l5INSTALLED: Vz tl- Iorj � 1, TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S 'TANK I.D.0 Al `7' Q 1 ��D. MANUFACTURED BY: I"t��, �(?�4`� ,r7 TANK CAPACITY IN GALLONS: 10 000 G DATE INSTALLED(MOlDAYJYEAR) "l+'I 11.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B- C ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ BO EMPTY 1 PRODUCT ❑ 1c MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ B M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW} D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C.AND ALL THAT APPLIES IN BOX D AND E 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN A. TYPE OF 99 OTHER SYSTEM ❑ 2 SINGLE WALL 4 SINGLE WALL IN A VAULT 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD Wt FIBERGLASS REINFORCED PLASTIC S. TANK MATERIAL ❑ 5 CONCRETE � 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 104% METHANOL COMPATIBLE W1FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY UMNG ❑ 4 PHENOLIC LINING C.INTERIOR ((� g UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING OR ❑ 5 GLASS LINING L� COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO_ D.EXTERIOR 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL. WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION Y; 91 NONE ❑95 UNKNOWN O 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION ❑ SPILL CONTAINMENT INSTALLED(YEAR} I OVERF1 L PREVENTION EQUIPMENT INSTALLED(YEAR) 4� E.SPILL AND OVERFILL,OtC, DROP TUBE YES�.- NO STRIKER PLATE YES NO DISPENSER CONTAINMENT YES NO IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U i SUCTION A 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U S 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 8 100% METHANOL.COMPACTIBLE WIFRP IC. PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A99 OTHER v ��T11 1 MECHANICAL UNE LFAlf f—I 2 UNE TIGH4NESS f'�3 CONTINUOUS YNTER5TITIAL a 4 ELECYAOMC UNE ❑5 AUTOMATIC PUM? �I 9g OTHER�� D. LEAK DEfiECTION r�u LJ TESTING Ilca� MONIFORING LEAI(pETECTOR SHUTpOWN I_J pETECTOR V.TANK LEAK DETECTION UND ❑ 1 VISUAL CHECK ❑ RECONC 2 MANUAL IN TENT RY ❑ 3 VAD MONITORING 4 GAUGING IC TANK ❑ 5 MON TORINGTER ❑ 6 TESTING TANK 7 CONTINUOUS MONITORING INTERSTITIAL ❑ 8 SIR ❑ TANK GAUGIINGAL ❑10 TESTING E MONTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES E NO ❑ 1.ESTIMATED DATE LAST USED(MO1DAYlYR) SUBSTANCE REMAINING GALLONS j INERT MATERIAL? L� THIS DORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO T!fE BEST OF MY KNOWLED� �5 TRUE r�NO CORRECT E TANK OWNER'S NAME - =� Csd�'Y?�`nt3 } / * �Df o,-wer 4 (PRINTE0651GNATURE} d�� LOCAL AGENCY USE ONLY THE STATE 1.D.N IS aidMPOSED OF THE FOUR NUMBERS BELOW TANK# COUNTY# JURISDICTION# FACILITY# STAPERMIT EXPIRATION DATE TE I.D.# _ cctt PERMIT NUMBER PERMlT APPROVED BYlDATE -7 0N FORM A,UNLESS A r� THIS FORM MU SHOULD O ACCOMPANIED BY AI PLOT P iLE THIS FORM W TH THE LOCAL AGENCY IMPLEMENTINGTHE GROUND STORA E TA NCURENT FORM A HAS BEEN FILE . F MUST BE COMPLETED K SNS.THIS FORM FORM B (6.95)