BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

• • STATE OF CALIFORNIA `ay STATE WATER RESOURCES CONTROL BOARD uym�, UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B 1 °4nan COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT O 3 RENEWAL PERMIT LJ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: i G I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) 0 /a D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MA KED,C MPLETE ITEM C. A ❑ 1 MOTOR VEHICLE FUEL 'X4 OIL B. C. ❑ to REGULAR UNLEADED O 3 DIESEL [:] 6 AVIATION GAS ❑ 2 PETROLEUM 80 EMPTY I7GI 1 PRODUCT ❑ ib PREMIUM UNLEADED E] 4 GASAHOL ❑ 7 METHANOL I '``� ❑ 1e MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 99 OTHER(DESCRIBE IN ITEM D.BELGM 7::p7 D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED / C.A.S.# ^�! III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXESA ,AND C,AND ALL THAT APPLIESINBOX D AND A. TYPE OF 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR UNER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL O 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/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 C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY UNING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100-1. METHANOL? YES— NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTON ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,E{F SPILL CONTAINMENT STALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) if I&W —7 DROP TUBE YES NO_ STRIKER PLATE YES_ NO_ DISPENSER CONTAINMEN YES_ NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A tfi DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A 94 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION MECHANICAL LME IFAK 2 UNE 9GHTNE55 3 WWINUOUS LNTERSTRML 4 ELEC NIC UNE O 5 AUTOIUTC PUMP O 99 OTHER DETECTOR TESTING MOMTCRING LEAK OMMM SHUT m V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL RECONCILIATION MONITORING ❑ 3 VADOZEMONITORING ❑ 4 AUTOMATGAUGING MONITORING TANK ❑ 5 GROUND MONTORINGTER ❑ TANK 6 TESTING 7 CONMON INUOU INTERSTITIAL ❑ 8 SIR ❑ 9 WEEK LY MANUAL ❑ 10 MOTESTINGHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER ORINVI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIM4TW DATE LAST USED(MO/DAYNR) 2,ETE QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTED 6 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THEJRGROU�STORAGE TANK REG ONS FORM B (6-95) 9 ./ae