BILLING_1997-2003 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA "��•• s STATE WATER RESOURCES CONTROL BOARD s' o UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SI ONE REM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 6 TANK REMOVED IDEA OR FACILITY NAME WHERE TANK IS INSTALLED: LAN D - O T C'f3 S. Prrs P--T 9q I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN / 1 A. OWNER'S TANK 1.0.a B. MANUFACTURED BY: ' `U�IL &5'1T&IPHG: JT C. DATE INSTALLED(MO/DAY/YEAR) 4- 1-9-7 D. TANK CAPACITY IN GALL IONS: 5' 6fad ILTANKCONTENTS IFA-11S MARKED,COMPLETE ITEM C. REGULAR A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ® 14UN LE e 3 DIESEL ❑ 6 AVIATIONGAS ❑ 2 PETROLEUM ❑ 1 PRODUCT lbPREMIUM 60 EMPTY �' 4 GASAHOL 7 METHANOL ❑ UNLEADED ❑ 5 JETFUEL ❑ ❑ 3 CHEMICAL PRODUCT E:] 95 UNKNOWN E] 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.S.AND C.AND ALL THAT APPLIES IN BOX D AND TR A. TYPE OF L�f i 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 ,� 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD L14 NG ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIORE] 5 GLASS LINING 6 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) I 1 OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) Lgg7 IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A*P2 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 U 3 POLYVINYL CHLORIDE(PVC)A*04 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 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 —meMONRONING ❑ 99 OTHER V.TAN LEAK DETECTION ��NNN 1�YISUAL CHECK �VENTORY RECONCILIATION ❑ 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING 6 TANK TESTING 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED IMO/DAY/YR) 2.ESTIMATED 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 APPLICANTSN (PRIMEb6 SIGNPTURE) �IG� �Nu1Ey I i4�q� C- a3 L', DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOURN E BELOW STATE LD.# COUNTY 9 JURISDICTION M FACIL'nY# TANK N OG) FT—F I I —F� mccowloill PERMIT NUMBER — PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FORM B (1291) • FILE THIS FORM WITH THWAL AGENCY IMPLEMENTING THE UNDERGROUND STOR TANK REGULATIONS ?7 �,Q �IPOROgN/6R{ q� J l0 pI li"/0-� 1 �"—