Laserfiche WebLink
e <br /> • SPATE OFCALIFORNIA `i <br /> STATE WATER RESOURCES CONTROL BOARD ' <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B ""` =: <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY NEW PERMIT O 3 RENEWAL PERMIT CHANGE OF INFORMATION 7 PERMANENTLY CLOSE <br /> ONE REM 5Lg_"t/ 2 INTERIM PERMIT O A AMENDED PERMIT TEMPORARY TANK CLOSURE t TANK REMOVED l <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: FLa Gl 3 J <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNERS TANK I.D.s I B. MANUFACTURED BY: �JI� <br /> C. DATE INSTALLED(MO/DAYMEAR) D. TANK CAPACITY IN GALLO z� O�O <br /> ILTANKCONTENTS IFA-I IS MARKED.COMPLETE ITEM C. <br /> A. ® 1 MOTOR VEHICLE FUEL 1:14 OIL B. C ® IaREGULAR UN EA ED 3 DIESEL 6 AVIATIONGAS <br /> O 2 PETROLEUM 0 W EMPTY 25 , PRODUCT O 10PREMIUM ! GASAHOL 7 METHANOL <br /> O 5 JET FUEL <br /> 0 3 CHEMICAL PRODUCT O 95 UNKNOWN O 2 WASTE 0 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D.BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.a: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.ANDC.AND ALLTHAT APPLIES IN BOXDANDE <br /> A. TYPE OF ® I DOUBLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER O 95 UNKNOWN <br /> SYSTEM 0 2 SINGLE WALL O A SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER <br /> B. TANK O I BARE STEEL O 2 STAINLESS STEEL EK 3 FIBERGLASS O a STEELCLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL 5 CONCRETE 6 POLYVINYL CHLORIDE O 7 ALUMINUM a 6 100% METHANOL COMPATIBLE W/FRP <br /> (Primary Tank) O 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN O 99 OTHER <br /> 1 RUBBER LINED F--] 2 ALKYD LINING 3 EPDXY LINING Q a PHENOLIC LINING <br /> C.INTERIOR 5 GLASS LINING y 6 UNLINED 95 UNKNOWN O 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES NO_ <br /> D.CORROSION O I POLYETHYLENE WRAP 2 COATING 3 VINYL WRAP { FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION C 5 CATHODIC PROTECTION Q 91 NONE 11ppww-�� 95 UNKNOWN O 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) _ <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION AQ 2 PRESSURE A U 3 GRAVITY A U " OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL A 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)AQa FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 9 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODICPROTECTIDN A U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION ® 1 AUTOMATIC LINE LEAK DETECTOR 0 2 LINE TGHTNESS TESTING Q MDNRORING Q W OTHER <br /> V.TANK LEAK DETECTION <br /> 1 VISUAL CHECK O 2 INVENTORY RECONCILIATION O 3 VADOZE MONITORING Cg a AUTOMATIC TANK GAUGING a 5 GROUND WATER MONITORING <br /> C 6 TANK TESTING ® 7 INTERSTITIAL MONITORING O 91 NONE 0 95 UNKNOWN O 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES O NO 0 <br /> SUBSTANCE REMAINING GALLONS INERTMATERIAL? <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICxreANTS NAME DATE <br /> IPxro a sioxAruRel ,..f I✓L S �DWk-�l-p. .G./ y -7 fT7 <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> STATE LD.# <br /> COUNTY 9 JURISDICTION 6 FACILITY 6 i7cy TANK 6 <br /> m O b ( O b <br /> PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE <br /> THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPUCATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FILE THIS FORM WITH THP r OCAL AGENCY IMPLEMENTING THE UNDERGROUND STr-•r1E TANK REGULATIONS <br /> FORME (1291) <br /> � 'No <br />