BILLING 1985-2003 - Laserfiche WebLink

Home Browse Search

- � Sou•':-r n STATE OF CALIFORNIA ti i STATE WATER RESOURCES CONTROL BOARD 4 UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: l c- 1. I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN + A. OWNER'S TANK I.D.* 1 i �*] a) B. MANUFACTURED BY: 14"� C. DATE INSTALLED(MOIDAYNEAR)•+1 6 D. TANK CAPACITY IN GALLONS: GJ�� ILTANKCONTENTS IFA-1 IS MARKED,COMPLETE BTEM C. A- ><1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. la REGULAR FADED ❑ 3 DIESEL 6 AVIATION GAS �1 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT 16PREMIUM ❑ 4 GASAHOL 7 METHANOL UNLEADED 5 JET FUEL 2 3 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE LEADED ❑ _. � 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: Ilf, TANK CONSTRUCTION MARK ONE ITEM ONLY IN ROXESA,B.AND C.AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM �K2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANKI 99 OTHER_ B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM B 100% METHANOL COMPATIBLE WIFRP (PrimaryTaRk) 9 BRONZE F7110 GALVANIZED STEEL�95 UNKNOWN ❑ 99 OTHER 1 RUBBER LINED �I 2 ALKYD LINING �<195 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.IN LINING —15 GLASS LINING ❑ 6 UNLINED UNKNOWN ❑ 99 OTHER 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(YEA RI N OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) 1411!+j4 IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A(91 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION Alp i SINGLE WALL A 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 U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL WICQATING A U 8 1009/6 METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION _ A 5 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑� 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING ❑ 7 NTERSTITI G ❑ 99 OTHER V.TANK LEAK DETECTION �❑ 1 VISUAL CHECK �2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING 5 GROUND WATER MONITORING 6 TANK TESTING 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1,ESTIMATEDATF USED(MOIDAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH ^" SUBSTANCE REMAINING #g_( GALLONS INERT MATERIAL? YES NOX THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE T OF AlY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED 6 SIGNATURE] - Is ,14 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW Z,3 I a& STATE 1.014COUNTY# JURISDICTION# FACILITY# TANK# o} PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE 1 THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED, Z , FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS i FORM R (12-91)