BILLING 1985-1993 (2) - Laserfiche WebLink

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C /I " STATE OF CALIFORNIA � s, STATE WATER RESOURCES CONTROL BOARD e• UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B g� a COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. °•"'°""�� MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 ERMANENTLV C E ONE ITEM F-12 INTERIM PERMIT ❑ 4 AMENDED PERMIT E:] 8 TEMPORARY TANK CLOSURE r8 TANK REMOVEJ� DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ,Z� lJ I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK 1.D.# B. MANUFACTURED BY: O C. DATE INSTALLED(MO/DAVA'EAR) D. TANK CAPACITY IN GALLONS: /��J/ Q II.TANK C NTS IFA-1 IS MARKED.COMPLETE ITEM C. 3 A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C• ❑ 1a RNLEADED ❑ 3 DIESEL ❑ 8 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT 1b PREMIUM ❑ 4 GASAHOL ❑ 7 METHANOL —1UNLEADED ❑ 5 JETFUEL 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 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.N: III. TANK CONSTRUCTION MARKONE ITEM ONLY IN BOXES A.13,AND C.ANDALLTHAT APPLIES IN BOXD AND A. TYPE OF1,.POUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM L j 2 GLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK E�rl BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ e POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PdmeryTAOk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INUNNIGR ❑ 5 GLASS LINING 6 UNLINED ❑ 95 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 Ew�t�5 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A 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 a CONCRETE A U 7 STEEL W/COATING A U 8 100% 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 O 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING ❑ 3 MONRORING ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING E] 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING O 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE O 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS IN 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE I.D.# COUNTY# JURISDICTION# FACILITY# TANK# PERMIT NUMBER PERMIT AP PROVED BV/DATE PERMIT EXPIRATION DAT 771 I HA THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM 8 (12-91) • l//�/(/ FOROM4&R6