BILLING 1986-1994 - Laserfiche WebLink

Home Browse Search

• STATE OF CALIFORNIA 0 STATE WATER RESOURCES CONTROL BOARD `'c6oY• s c + a UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B 0 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ONE ITEM ❑ 2 INTERIM PERMIT E] 4 AMENDED PERMIT 7 ANENTCLOSED ONSITE 6 TEMPORARY TANK CLOSURE 6 TANK REMOVED D DBA OR FACILITY NAME WHERE TANK IS INSTALLED: al0 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I. D.# / B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) 0. TANK CAPACITY IN GALLONS: II.TANK CONTE S IFA-11SMARKED,COMPLETE ITEM C. A. ❑ 1 M R VEHICLE FUEL ❑ 4701L BC. ❑ 1aUNEADED 3 DIESEL 6 AVIATION GAS ETROLEUM ❑ 8 1 PRODUCT 1b PREMIUM 4 GASAHOLCHEMICALPRODUCT ❑ 9WN ❑ 2 WgSTE UNLEADED 5 JET FUEL ❑ 7 METHANOL 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOTMARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.# III. TANK CONSTRUCTI N MARK ONE ITEM ONLY IN BOXESA,B,AND C.AND ALL THAT APPLIES IN BOX D AND A. TYPE OF ❑ DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER E:] 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ 1 ARESTEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL 5 CONCRETE O 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM 1:19 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED 2 KY LINING ❑ 3 EPDXY LINING C.INTERIOR 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO D.CORROSION ❑ 1 POLYETHYLENE WRAPATING E:] 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) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) 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 p U 3 GRAVITY R B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 85 UNKNOWN A g 0 C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL p U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELW/COATING PROTECTION p U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U B 100% METHANOL COMPATIBLE WIFRP A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 MONITORING ❑99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 DOZEMONITORING ❑ 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(M lDAV/V ) 2.ESTIMATED QUANTITY OF y SUBSTANCE REMAINING GALLO3•WAS TANK FILLED WITH YES NO❑ NS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY APPLICANTS NAME KNOWLEDGE, IS TRUE AND CORRECT (PRINTED a SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE LD.# COUNTY# JURISDICTIONp FACILITY �u= Tq PERMIT NUMBER PERMIT APPROVED BV/DATE PERMIT )l P IRRATION DDi� FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOR0g7411-R5