BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM m EDBAOR ;FACILITY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT �-.�/ ❑ 2 INTERIM PERMIT ❑ 6 AMENDED PERMIT LJ 5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED ON SITE ❑ 8 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED Q NAME WHERE TANK IS INSTALLED: Z�J z'" I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN If A OWNER'S TANK I.O.i gZQ; C. DATE INSTALLED(MOVDAYiY'EAfl) EEEH II.TANK ONTENTS IFA-11SMARKED,COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ d OIL S. C. ❑ ipURE NLEADED REGULAR 3 DIESEL ❑ 9 AVMTIONGAS ❑ 2 PETROLEUM ❑ SO EMPTY ay PRODUCT ❑ 1E PREMIUM d GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ DS UNKNOWN ❑ 2 WASTE UNLEADED 5 JET FUEL ❑ 2 LEADED 99 OTHER (DESCRIBE IN ITEM 0. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.is III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALLTHAT APPLIES IN BOX A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ d SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 6 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ S POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ S 100% METHANOL COMPATIBLE W/FRP (PdmwyTmk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 05 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 9 UNLINED ❑ 95 UNKNOWN Q 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ s FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 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 U d FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 9 CONCRETE A U 7 STEEL W/COATING A U B 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODICPROTECTKNN A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 MONRORI ALL ❑ 99 OTHER V.TANK LEAK DETECTION �JFff�sl L CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 7 VAPOR MONITORING❑ d AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING -( TANK TESTING ❑ 7 INTERSTITIALMONITORWG ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERTMATERIAL? YES ❑ NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME pp7E IvaxrED s slc.AT. LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILTTY# TANK# STATE I.D.# ® I I I I I 110[j] fARAYYzs' PERMIT NUMBER PEflMR APP BQ DBV/DATE 26 PERMIT EXPIRATION DATE FORMS (9-9q THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPUCATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORCV1 M 1