BILLING_1997-2003 - Laserfiche WebLink

Home Browse Search

STATE OFCAUFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B 1 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 0] 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT E] 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Nacc, I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNERS TANK I.D.♦ I I B. MANUFACTURED BY: xe)�XeS C. DATE INSTALLED(MCVDAY/YEAR) 3 1Ifl g gj D. TANK CAPACITY IN GALLONS: 21J G n V II.TANK CONTENTS IF A-1 IS MARKED.COMPLETE ITEM C. la REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C ❑ 10 PROAUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ 80 EMPTY �1 PRODUCT ❑ is MIDGdRADE UNLEADED ❑ 5 JET FUEL ❑ 8 MM ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHERIDFSCRISEPoLTEMD.BELOM 0. IF(Ai)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A S.k III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A S.AND C.AND ALL THAT APPLIES IN BOX D AND E 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN A. TYPE OF �Ea ❑ 99 OTHER EM SYST ❑ 2 SINGLE WALL 4 SINGLE WALL IN A VAULT ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC R. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WlFRP (Pmmy Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH IWA METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION ❑96 UNKNOWN ❑ 99 OTHER PROTECTION 5 CATHO CPROTECTION 91 NONE ^ SPILL CONTAINMENT INSTALLED(YEAR) OVER FILL PREVENTION EQUIPMENT INSTALLED(PEAR) E SPLLL AND OVERFW.,8IL DROPTUBE YES NO— IV. O__ STRIKER PLATE YES_ NO_ DISPENSER CONTAINMENTNT YY S NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A—U 12 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL ALU 1 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 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 ©1 u um ❑2 TFs ®� � �4 1�r 5 DON 0 orHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK El RECONCIUATION�Y ❑ 3 MONITORING ❑ 4 GAUGGIIINAG C TANK ❑ 5 GROUNDWATERF7 ANNUALTANK VADOZE8 TESTING © 7 CMONITORIOG 94TERSTTTLAL ❑ 8 SIN ❑ 9 TWEEKLY JK GAWING� ❑10 TESTING TANK ❑ 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAVJYR) 2 ESTIMATED QUANTITY OF I 3.WAS TANK FU I ED WITH YES ❑ NO❑ SUBSTANCE REMAINIG GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND.TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNERS NAME DATE R �� (PRN1ID a swNATURET I LOCAL AGENCY USE ONLY THE STATE LD.NUMBER IS COMPOSED OFTH�E FOUR—LNUMBERS BELOW � COUNTY t JURISDICTION L RISDICTION R FACI� TA T STATE I.D:# m L_J_� I I I III I PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A POW AiAMTiON.FORM A.UNLESS A CURRENT FORM A HAS BEEN FUER.�C MUST BE STORAGE FORREGULAINSTAULATIONSTHIS FORM SHOULD BE ACCOMPANIED BY A PL FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING 1}I�EHGROUND FORM B (695)