BILLING_1997-2003 - Laserfiche WebLink

Home Browse Search

STATEOFCAUFORMA STATE WATER RESOURCES CONTROL BOARD e UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT .A% 1--Ii CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL ONE REM OSE ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSUREr 1p �O 6 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: -lCl U I H L-kN(� e lwta�J 4?> S., I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# B. MANUFACTURED BV: c ;l y�� .TrN Q(1 / C. DATE INSTALLED(MO/DAY/YEAR) 'j -1'I , D. TANK CAPACITY IN GALLONS: ILTANKCONTENTS IFA-I IS MARKED,COMPLETE ITEM C. A. i 1 MOTOR VEHICLE FUEL ❑ 4 OIL g, C ❑ LREGULDDA R 3 DIESEL UNLEADED ❑ 8 AVIATION GAS AA ❑ 2 PETROLEUM a SO EMPTY 1 PRODUCT lb PREM IUM 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN � 2 WASTE ❑ 2 LEADEDD ❑ 5 JET FUEL ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) 0. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.a: III. TANK CONSTRUCTION MARK ONE ITEM ONLYIN BOXESA,8,ANDC,ANDALLTHATAPPLIES IN BOXDANDE A. TYPE OF 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER S. TANK ❑ I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ S 10D% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING } ' 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 10D% METHANOL? YES %.."NO D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAPL'T4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) �� OVERFILL PREVENTION EQUIPMENT INSTALLED(NEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A 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 V 3 POLYVINYL CHLORIDE(PVC)A'TjW4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U S IDD% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC ROTECTION A U 95 UNKNOWt> A U 99 OTHER D. LEAK DETECTION ❑ i AUTOMATIC LINE LEAK DETECTOR FPr2 LINE TIGHTNESS TESTING MONRORING ❑ 99 OTHER V.TANX LEAK DETECTION VISUAL CHECKINVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING AUTOMATIC TOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING TANK TESTING � INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED OUANTITV OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME (PRINTED a SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE 04COUNTY# JURISDICTION# FACILITY# TANK# m PERMIT NUMBER PERM IT APPROVED BV/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 THj#AL AGENCY IMPLEMENTING THE UNDERGROUND STOR JTANK REGULATIONS FORME (1291) _ �_ y FDR60015 R1