BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

'<pOU�1 � WATE OF CAUPORNA �� STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B "m� e COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. "�� MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE REM F—] 2 INTERIM PERMIT F7 4 AMENDED PERMIT L�Ji 6 TEMPORARY TANK CLOSURE ® 8 TANK REMOVED Op DBA OR FACILITY NAME WHERE TANK IS INSTALLED: / ' 1 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.# O B. MANUFACTURED BY: K W. C. DATE INSTALLED(MO/DAYNEAR) N D. TANK CAPACITY IN GALLONS: OOO ILTANK CONTENTS IFA-11SMARKED.COMPLETEITEM C. 1 MOTOR VEHICLE FUEL F-] 4 OIL S. C. 1:11aUNLEADED 3 DIESEL ❑ e AVIATION GAS REGULAR A ❑ 2 PETROLEUM ❑ 80 EMPTY T9 1 PRODUCT ❑ tb PREMIUM4 GASAHOL ❑ 7 METHANOL 3 CHEMICALPRODUCT 95 UNKNOWN WASTE ❑ ❑ ❑ UNLEADED ❑❑ 99 JL 2 LEADED OTHER (DESCRIBE IN ITEM D. BELOW) 2 D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.8: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.S.AND C,AND ALL THAT APPLIES IN BOX A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ® 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED Rt 96 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION fo 91 NONE F-]95 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A@ 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND Q i 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 8 CONCRETE A U 7 STEELW/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 ❑ i AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ a INTMO ❑ W ERSITTIAOTHER V.TANK LEAK DETECTION F❑ 1 VISUAL 6 L CHECK F-12 INVENTORY RECONCILIATION E:] 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING ❑ TANK TESTING ❑ 7 INTERSTITIAL MONITORING ® 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAV/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH S_ �y SUBSTANCE REMAINING A/ONC GALLONS NERT MATERIAL? VES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME DATE (P61WEO431GNA , LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW G As)-/C 44 COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# ® D 0 l R S 6 a PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE FORM a (&90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOROOM&Ip