BILLING_1997-2003 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA �• STATE WATER RESOURCES CONTROL BOARD J�� UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT \ EJ-.{II�� S-CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT -TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACHM NAME WHERE TANK IS WTALLED: N'R o 7a(:7 (c>33S ST Lh C Iti I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNERS TANK I.D.4 3 I B. MANUFACTURED BY: Xe�Xes C. DATE INSTALLED(MO'DAYNEAR) 3 11, g D. TANK CAPACITY IN GALLONS: I Q U oV H.TANK CONTENTS IF A"1 Is MARKED.COMPLETE ITEM c. 1 MOTOR VEHICLE FUEL ❑ 1 OIL B C. t•REGULAR UNLEADED ® 3 DIESEL 6 AVIATION GAS 1 PRODUCT 10 PRBYAJ UNLEADEDA GASAHOL 7 METHANOL A ❑ 2 PETROLEUM ❑ SO EMPTY 1e MDORNE UNLEADED5 JET FUEL 6 MRS ❑ 3 04BACAL PRODUCT ❑ 05 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 8 99 OTHER MESCRISE N ITEM D.BHOWI D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.0: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B,AND C,AND ALL THAT APPLIES IN BOK D AND E }CSL A. TYPE OF 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 NTERNAL 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 RBNFoRcED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100%METHANOL COMPATIBLE w/FRP TftWY T=10 ❑ 9 BRONZE .. ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER G INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOUC LINING LINING OR ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING LS UWNG MATERIAL COMPATIBLE WITH IDD% METHANOL? YES_ NO_ D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS RENFORCED PLASTIC CORROSION 91 NONE % UNKNOWN B9 OTHER PROTEOTM I� 5 CATHODIC PRGTECiwN ❑ ❑ ❑ SPILL CONTAINMENT i ALLED(YEAR) OVERFILL�ENTION EQUIPMENT INSTALLED(YEAR) E SPLLL AND OVERFILL,etc. DROP TUBE YES � NO— STRIKER PLATE YES V NO_ DISPENSER CONTAINMENT YES_ NO IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION 11�2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLU 2 DOUBLE WALL A U 3 LNED 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)ACU FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 6 100% METHANOL COMPATIBLE WrRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER - D. LEAK DETECTION 01 UE UM ❑2 U ®3 uornaANc� 4 uc s w1au s,AIP ❑ 93-HER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCILIATION ❑ 3 VADOZEMONITORING ❑ 4 AUTOMATIC TANK ❑ 5 GROUND GAUGING INF a 6 TESTINGTANK T I ONTINU )SING INTERSTRML ❑ B SIR- ❑ ANK 9 TWEEKLY MAGAUGINUAL ❑10 MONTHLY TANK ❑ 95 UNKNOWN ❑09 OTHER TESTING VI.TANK CLOSURE INFORMATION powm NT CLOSURE IN-PLAcE) 1.ESTIMATED DATE LAST USED WmAY/YR) 2.FsnMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TT OWNEFATLIR 4 LOCAL AGENCY USE ONLY THE STATE LD.NUMB IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY* JURISDICTION A FACILITY• TANK A I STATE I.Dl m C= ( �' i_ �, x• PERMIT NUMBER PERMIT APPROVED BY/DATE '- PERMIT E MRAnM DATE THIS FORM MUST BE ACCOMPANIED BY A PERWT AAPPPPAOLTON-FORM A,UNLESS A CURRENT FORMA HAS BEEN F C MUST SE COMPLETED FOR INSTALLATIONS THIS FORM SHOULD BE ACCOMPANIED BY A PLOW RLE THIS FORM WITH THE LOCAL AGENCY W PLEMENTNG lWDERGROUND STORAGE TANK REGULATIONS FORM B (6.95)