BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

jaaW aCla STATE OF CALIFORNIA `Pa STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B tl°' =^ ^ `a,.el COMPLETE A SEPARATE FORM FOR E H TANK SYSTEM. MARK ONLY1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSEP O ONE REM 18 2 INTERIM PERMIT O 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN A OWNER'S TANK I.D.N B. MANUFACTURED BY: CA M C. DATE INSTALLED(MOIDAYNEAR) �� D. TANK CAPACITY IN GALLONS: / II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. J k ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. Is REGULAR UNLEADED V_T3 DIESEL ❑ 6AVIATIONGAS F-12 PETROLEUM ❑ 80 EMPTY ❑ I PRODUCT lb PREMIUM UNLEADED L 4 GASAHOL 7 METHANOL tC MRgRADE UNLEADED 5 JET FUEL B VB ❑ 3 CHEMICALPRODUCT 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED Ed 99 OTHER(DESCRIBE NREM D.BELOW( D. IF(A.I)ISNOTMARKED, ENTER NAME OFSUBSTANCE STORED C.A.S.4: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF ❑ I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM I yl 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER TT B. TANK ❑ I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL F__j 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE NFRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING O 6 UNLINED 95 UNKNOWN ❑ 99 OTHER COATINGIS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION - PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,116 SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROPTUBE YES_ NO_ STRIKER PLATE YES_ 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 A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 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 I 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 B CONCRETE A U 7 STEEL WICOATING A U B 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 AIECINaou UK LPA" NE Ta❑2 UKss O3 CWM=1 WEASTMAL ❑4 REC C UK ❑5 AUTOMM MW E:] 99 orHER aElECfaN N!rI04a �TMM LM"MncTOR PNUTaaWN V.TANK LEAK DETECTION ANNUALI ❑ 1 VISUAL CHECK ❑ 2 ANUAL INVENTRE ONCILIATIONORY ❑ 3 MONIITORING VAOZE ❑ 4 GAUGING AUTOMATIC TANK ❑ S GROUND WAMNTORINGTER ❑8 TES INGTANK ❑ 7 MON INUONUGS INTERSTITIAL ❑ B SIR ❑ 9 WAEAEKLYA MAIGINUAL ❑ 10 MANUAL HLY TANK ❑ 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 2 ILL 1 ESTIMAT€�D 0 TE LABT USED(MOA7AV YR) 2 SU UTBSTANCE REMAI NGTITY F GALLONS 3 WASNERT MATERIAL?ILLED H YES ❑ NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTED A MGNAWRE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTYN JURISDICTION N FACILITY#64vg TANK MQ STATE I.D:# 3 ® S 3 1 G' / 7 `� z PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE l THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPL N-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. C MUST BE COMPLETED FO INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT P E THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING 'VGROUND STORAGE TANK REGULATIONS FORME (6 95) -II ��"I FORM31&R7