Laserfiche WebLink
STATE OF CALIFORNIA a <br />STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM BCOMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br />MARK ONLY Q 1 NEW PERMIT 0 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION I—j 7 PERMANENTLY CLOSED ON SITZ <br />ONE ITEM O 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ g TEMPORARY TANK CLOSURE jYbl�{ 8 TANK REMOVED <br />DBA OR FACILITY NAME WHERE TANK IS INSTALLED:I�1.4/'j nl j UF'IZS � m <br />I. I NNR UCDld1iP I NN COMPLETE ALL ITEMS - SPECIFY IF UNKNOWN <br />A. OWNER'S TANK I.D.# B. MANUFACTURED BY: <br />C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: <br />A. ❑ 1 MOTOR VEHICLE FUEL O 4 OIL <br />B. <br />C. laURNELGULAR ® 3 DIESEL g AVIATION GAS <br />2 PETROLEUM 0 90 EMPTY <br />1 PRODUCT <br />O 10PREMIUM d GASAFK)L 7 METHANOLUNLEADED <br />3 CHEMICALPRODUCT O 96 UNKNOWN <br />O 2 WASTE <br />O 5 JET FUEL <br />O 2 LEADED <br />❑ 1 BARE STEEL <br />0 2 STAINLESS STEEL <br />99 OTHER (DESCRIBE IN ITEM D. BELOW) <br />D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. 4: <br />III. IANK GUNSTRUCTION MARKnMFITFMnNI,.M ....Auer ..�., .,...,..._.....__.._ <br />A. TYPE OF <br />1 DOUBLE WALL <br />3 SINGLE WALL WITH EXTERIOR LINER <br />F-1 95 UNKNOWN <br />SYSTEM <br />Q 2 SINGLE WALL <br />❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) <br />99 OTHER <br />B. TANK <br />❑ 1 BARE STEEL <br />0 2 STAINLESS STEEL <br />❑ 3 FIBERGLASS <br />4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC <br />MATERIAL <br />Q 5 CONCRETE <br />❑ 6 POLYVINYL CHLORIDE <br />7 ALUMINUM <br />8 IW% METHANOL COMPATIBLE W/FRP <br />(PrimaryTa* <br />O 9 BRONZE <br />10 GALVANIZED STEEL <br />95 UNKNOWN <br />O 99 OTHER <br />4 FIBERGLASS PIPE <br />D 1 RUBBER LINED <br />O 2 ALKYD LINING <br />E::] 3 EPDXY LINING <br />O 4 PHENOLIC LINING <br />C.INTERIOR <br />0 5 GLASS LINING <br />O 8 UNLINED <br />95 UNKNOWN <br />O 99 OTHER <br />IS LINING MATERIA COMPATIBLE WITH 100% METHANOL? <br />YES_ NO— <br />9 GALVANIZED STEEL <br />D. CORROSION <br />1 POLYETHYLENE WRAP <br />O 2 COATING <br />3 VINYL WRAP <br />O 4 FIBERGLASS REINFORCED PLASTIC <br />PROTECTION <br />O 5 CATHODIC PROTECTION 91 NONE <br />O 95 UNKNOWN <br />O 99 OTHER <br />IV. PIPING INFORMATION CIRCLE A IFARDVFGRn11MnnR n ICuunFononuun <br />A. <br />SYSTEM TYPE <br />A U <br />1 SUCTON <br />A U <br />2 PRESSURE A U <br />3 GRAVITY A U <br />99 OTHER <br />B. <br />CONSTRUCTION <br />A U <br />1 SINGLE WALL <br />A U <br />2 DOUBLE WALL A U <br />3 LINED TRENCH A U <br />95 UNKNOWN A U 99 OTHER <br />C. <br />MATERIAL AND <br />A U <br />1 BARESTEEL <br />A U <br />2 STAINLESS STEEL A U <br />3 POLYVINYL CHLORIDE (PVC) A U <br />4 FIBERGLASS PIPE <br />CORROSION <br />A U <br />5 ALUMINUM <br />A U <br />9 CONCRETE A U <br />7 STEEL W/ COATING <br />A U <br />8 100% METHANOL COMPATIBLE W/FRP <br />PROTECTION <br />A U <br />9 GALVANIZED STEEL <br />A U <br />10 CATHODIC PROTECTION <br />A U 95 UNKNOWN <br />A U <br />99 OTHER <br />D. <br />LEAK DETECTION <br />0 1 <br />AUTOMATIC LINE LEAK <br />DETECTOR Q 2 LINE TIGHTNESS TESTING 3INT kl <br />99 OTHER <br />MONITORING <br />V. TANK LEAK DETECTION <br />1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION 3 VAPOR MONITORING 4 AUTOMATIC TANK GAUGING Q 5 GROUND WATER MONITORING <br />6 TANK TESTING [::] 7 INTERSTITIALMONITORING O 91 NONE 95 UNKNOWN O 99 OTHER <br />1. ESTIMATED DATE LAST USED (MO/DAY/YR) I 2 ESTSUBSTANCEMATEDREMAIN <br />INGREMAINING GALLONS ANTITY OF I 3 WA INERTMATERIAL? YES E NO <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />APPLICANT'S NAME DATE <br />(PRINTED A SIGNATURE( <br />LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OFTHE FOUR NUMBERS BELOW <br />COUNTY # FACILITY # TANK # <br />STATE LD.# ® Lia� <br />PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE <br />FORM B (4-9q I HIS FUHM MUSI BE ACCOMPANIED BY A PERMIT APPLICATION • FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. <br />FORMS PA <br />