BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA `ew„« STATE WATER RESOURCES CONTROL BOARD o 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 CL9Seo--ON SITE ONE REM ❑ 2 INTERIM PERMIT Eil�4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Q,E'4Dv(pY.,J V 8 �0 Q I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# 3 B. MANUFACTURED BY: M O DE/Zpp N �/E(—D I r✓G C. DATE INSTALLED(MO/DAY/YEAR) 19 F-7 D. TANK CAPACITY IN GALLONS: f O 000 II.TANK CONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. A. LEI<MOTOR VEHICLE FUEL ❑ 4 OIL B. C. �❑ la REGULAR UNLEADED 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY Q�PRODUCT U 'b PREMIUM UNLEADED 6 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ la MIDGRADE UNLEADED ❑ 5 JETFUEL ❑ 8 M85 ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE N ITEM D.BBAVl) D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S. III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C.AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF [ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE [D T ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PH—ry TNW ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING E:] 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR F-15 GLASS LINING E5-8 8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP �!47FIOBERGLASS REINFORCED PLASTIC CORROSIONPROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 CNE ❑95 UNKNOWN THR E.SPILL AND OVERFILL,etc. SPILLCONTAINMENT-�TALLED(YEAR) OVERFlLL P�FVENTION EQUIPMENT INSTALLED(YEAR) DROPTUBE YES_ NO_ STRIKER PLATE YES_ NO_ DISPENSERCONTAINMENT 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 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 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A @4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U T STEEL W/COATING A U 8 10D% 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 [:]' MII N M LL ME LFAI( ❑2 UIE TIGH W I"I�L'TCON9NUW5 INIERSTT4IL EIECmOMp UNE �5 AUiOANIN:PUW ❑ 99 OTHER OEIECTOR iESTNp IA^NfGNMi [EAN OEIE U 9MIINNN V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECO CILIUAL ATION RV ❑ 3 VADOMONITORING �GAUGNGAUTOMATIC TANK ❑ 5 MONITORINGWATER ❑6 TEANNUAL STING CONTINUOUS U INTERSTITIAL [:] 8 SIR 9 WEEKLY MANUAL 10 MONTHLY TANK MO95 UNKNOWN❑ TANKGAUGING ❑ TESTING ❑ ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED DATE LAST USED(MOIDAY(YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK RULED WITH YES ❑ NO SUBSTAGE REMAINING GALLONS INERTMATERIALT THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME 11�� OV G /vtk SS (ZO OATE (PRNTEDa SIONAN") 1J FD vtrr14-R/vi Ae-- LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITYM 09 TANK# Do STATE I.D:# g' /30 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 P1.6y FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE!;MDERGROUND STORAGE TANK REGULATIONS FORM B (6-95) S