BILLING 1985-2000 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA ` STATE WATER RESOURCES CONTROL BOARD o UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B LL m COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED / DBA OR FACILITY NAME WHERE TANK IS INSTALLED: p W- I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.0 Q O 2 B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/9EAR) �j q I. �(>G� aG.-T/ D. TANK CAPACITY IN GALLONS: ITANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEEMWC.T A1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C, ❑ 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT II❑��,y/lb PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 95 UNKNOWN p WAS LJ 1c MIDGRADE UNLEADED E::] 5 JETFUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOM D. IF(Al)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.p: 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 UNER ❑ 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 W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTanya ❑ 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 9 VEUNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 10D% METHANOL? S NO_ D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN 99 OTHER E.SPILL AND OVERFILL,#SC. SPILL CONTAINMENT I TALLED(YEAR) OVERFILL P VENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES NO_ STRIKER PLATE YES NO DISPENSER CONTAINMENT YES 34 NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER S. CONSTRUCTION A U 1 SINGLE WALL A 2DOUBLE 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)AI&74 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 A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 01 MECHAMCAL LINE LEAK ❑2 UNE TSWNESS ❑3 COMINUWS INIERSTDIAL ❑4 ELEMONIC UNEE:l 5 AUTOWIX WAP O 99 OTHER - V. TESTNG MOMTORNG LFAK OE MOR SNU100WN V.TANK LEAK DETECTION 7 0 1 VISUAL CHECK ❑ 2 RECONCILIATIONANUAL ORY ❑ 3 MONITORING VAE ❑ 4 GAUGING NGAUTOMATIC TANK ❑5 MON TORINGGROUNDWATER F-16 TESTINGANNUAL TANK MONITORCONTINUOUS ❑ 8 SIR ❑ 9 TANEK K GA MANUAL E:]10 MONTT HLY NG TANK ❑ 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES E] NO 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 d SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY#00377 TANK# STATE I.D:# m = AAUD I 8' [.R PERMIT NUMBER PERMIT APPROVED BY/DATE 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 PJFILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THFORGROUND STORAGE TANK REGULATIONS FORM B (6.95) IIlIDlo U5