BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD s UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B ~° ( 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 ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE �® 8 TANK REMOVED 0 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.# u4t,&- B. MANUFACTURED BY: Ja C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: U[f� II.TANK CONTENTS IF A•1 IS MARKED,COMPLETE ITEM C. A �1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. 1A REGULAR UNLEADED 3 DIESEL ❑ 6 AVIATIONGAS F-12 PETROLEUM ❑ BO EMPTY ❑ 1 PRODUCT ❑ 1D PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ Ie MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BERM D. IF(XI)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 UM040 M SYSTEM 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ B POLYVINYL CHLORIDE ❑ 7 ALUMINUM [j 8 100% METHANOL COMPATIBLE W/FRP (PHmvy Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 85 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ i RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY UNING ❑ 4 PHENOLIC LINING � LINING OR ❑ 5 GLASS LINING M 6 UNLINED E:] 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP E] 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,etc. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTAI I En(YEAR) DROP TUBE YES_ NO_ STRIKERPLATE YES_ NO_ DISPENSER CONTAINMENT YES NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IFAPPLICASLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 96 UNKNOWN A U 99 OTHER C. MATERIAL AND Kul)1 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 6 CONCRETE A U 7 STEEL W/COATING A U a 100%METHANOL COMPATIBLE WFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 IEGHMAdI LR IFAK 02UINE11GIRNESG ❑3 WIRMIWG IIIIBt51RIAL 4 MECRKNIC LNE O 5 AVfdMTIL ww Q 99 OTHER �lX El GE1ECfGP TESING WIROBNG LFAR 9E1ECi0B SMIIWWN V.TANK LEAK DETECTION ❑ 1 WSUAL CHECK ❑ 2 RMANUAL ECONCILIATION MONITORING ❑ 3 VADOZEMONITORING ❑ 4 AUTOMATICCTIC TANK ❑5 GROUNDWAMONITORING ❑ B ANNUAL TESTING ❑ 7 CONTINOUOU INTERSTTML E] 8 SIR ❑ e WE�TANKAUGINGY NUAL ❑10 MONTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER MONITSTIN VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE LN-PLACE) 1.ESTIMATED D)17E T U (MO/DAY/YR) 2.ES TIMATE OUAKI T'OF 3.WAS TANK FILLED WITH YES ❑ NO ` SUBST EREMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PE OF PE JURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRU AND CORRECT TANK OWNERS NAM /- / - DATE (PRIMED451fiNATUREI /, Ill' //`a NO 7 LOCAL AGENCY USE ONLY THE STATE I.D.NUM R IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY If JURISDICTION# FACILITY It TANK# STATE I.D.# m PERMIT NUMBER PERMIT APPROVED BV/DATE PERMIT EXPIRATION DATE ) m THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPI `ION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. "-'M C MUST BE COMPLETED FOR INSTALLATIONS-THIS FORM SHOULD BE ACCOMPANIED BY A PLOT 11 FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING TI .�)ERGROUND STORAGE TANK REGULATIONS FORM B (6-95)