BILLING_1995-2007 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD i UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B W I, e �•lI�O1,N.� . 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 ❑ 9 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: LJ r I; /" Ca r rl bC I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN / A. OWNERS TANK I.D.# B. MANUFACTURED BY: moje rM We(di C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: 9, 000 II.TANKC NTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. 4UNL ULAR O 3 DIESEL ❑ 7 METHANOL AVIATION GAS F--] 2 PETROLEUM ❑ 60 EMPTY � PRODUCT a lb PREMIUM 4 JETFUEGASAHOL ❑ UNLEADED ❑ 5 ET FUEL 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C.ANDALLTHAT APPLIES IN BOX D AND A. TYPE OF LJ 1 DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS d4 STEEL CLAD Wl FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE O 6 POLYVINYL CHLORIDE [::] 7 ALUMINUM S 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED 2 ALKYD LINING ❑ 3 EPDXY LINING 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING Fu�<UNLINED ❑ 95 UNKNOWN 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) 9 S OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) p'- IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION p 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A(f)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 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A a>6 100% 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 ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING MONRORING' ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑�2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING '❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING vl ' INTERSTITIAL MONITORING ❑ 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 YES [7 NO ❑ SUBSTANCE REMAINING GALLONS IN MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED 6 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OFTHE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# ® © S- _.. 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. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORMS (12-91) • FOR004B116 •