BILLING_1997-2003 - Laserfiche WebLink

Home Browse Search

rL • STATE OF CALIFORNIA 'c STATE WATER RESOURCES CONTROL BOARD s dam, UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B =: _ , COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT -_2ff___CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 0 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: A(kCO 1�0.0 (,t 3°)S N I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.• B. MANUFACTURED BY: �(e,(j`+,�,5 C. DATE INSTALLED(MOIDAYIYEAR) 3 I A j D. TANK CAPACITY IN GALLONS: 20 IL TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C• to REGULAR UNLEADED _3DIESEL ❑ 6 AVIATION GAS A ❑ lb PREMIUM UNLEADED 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ S0 EMPTY �1 PRODUCT ❑ 1c MIDGRADE UNLEADED 5 JETFUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 89 OTHER(DESCRIBE RI TIT9.I D.BELOYQ D. IF(At)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.R III. TANK CONSTT�R((UCTION MA RK ONE ITEM ONLY IN BOXES A.S.AND C.AND ALL THAT APPLIES IN BOX D AND ,IG`�, I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXDD EXTERIOR UNER ❑ 5 INTERNAL BLAMER SYSTEM ❑ 95 UNKNOWN A. TYPE OF SYSTEM ❑ 2 SINGLE WALL F74 SINGLE WALL IN A VAULT ❑ 99 OTHER ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD Wl FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP TnmaTy Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER UNED ❑ 2 ALKYD UNING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC UNING C.INTERIOR ❑ ❑ LINING OR ❑ 5 CUSS LIVING �8 UNLINED 95 UNKNOWN 99 OTHER COATING IS UNING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FlBERGL.A`+5 REINFORCED PLASTIC CORROSION - 91 NONE ❑95 UNKNOWN ❑ 99 OTHER PROTECTION 5 cATHODICPRGTECTIDN ❑ SPILL CONTNNMENfI ALLED(YEAR) OVERFILL PHEVENNON EOUIPMENT SPEINSTALLED CONTAINMENT E SPILL AND OVERFILL,BTC. DROPTUBEYES v NO__ STRIKER PLATE YES- NO_ DISPENSER CONTAINMEM YES_ NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,130TH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION U 2 PRESSURE A U 3 GRAVITY A U 4 FLE)OBLEPIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL 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(+YL FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U B 100% METHANOL COMPATIBLE WIFRP f FRGTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D LEAK DETECTION ❑tI� uL Lru IFnrt L2 ®3 aNlw ^rt�m"'Lu ❑4OAI s ""'°' ❑ 99 oTHeR V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RRECONCRIATIONORV ❑ 3 VADOZE ❑ 4 AUTOMATIC C TANK ❑5 MONITORINGOUND S ❑6 TESANN7INGTANK Eq7 CONTINUOUS INTERSTITIAL ❑ 8 SIR. El TWM-K CAUL NGTPSTINAL ❑10 MONTHLY TANK ❑ 95 UNKNOWN ❑99 OTHER MONITORING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE W-PLACE) 1.ESTIMATED DATE LAST USED(MCIDAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH .ES ❑ NO O SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND O THE BEAT OF MY KNOWLEDGE,IS TRUE AND CORRECT 7J IIS l9 a TANK OWNERS DATE NAME l'� (PRNTm 451GNATURlT LOCAL AGENCY USE ONLY THE STATE I.D.NUMB R IS COMPOSED OF THE FOUR NUMBERS COUNTY R JURISDICTION R FACILITY R yT-A-NKK R- STATE I.D.A m LJ J J S C) 3 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT E%PIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPU A'0N.FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT pe THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING TH GROUND STORAGE TANK REGULATIONS FORM B (695)