BILLING - Laserfiche WebLink

Home Browse Search

SPATE OF CALIFORNIA o STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B l/ COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ® 7 PERMANENTLY CLOSED ONSITE ARK REM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED I ONE DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I d 1 e w 1 1 d Market " I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN Unknown �� fly B. MANUFACTURED BY: A. OWNER'S TANK I.D.>r C. DATE INSTALLED IMOIDAVA'EAR) Unknown D. TANK CAPACITY IN GALLONS: 1 O 0 ILTANKCONTENTS IFA-11S MARKED,COMPLETE ITEM C. 1a REGULAR n 3 DIESEL ❑ 6 AVIATION GAS ❑ i MOTOR VEHICLE FUEL ❑ 4 OIL B. C• ❑ UNLEADED L"~Jj 4 GASOHOL [DD. ❑ 1 PRODUCT ❑ tb PREMIUM 5 JETFUEL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ BO EMPTY UNLEADED ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED © 99 OTHER (DESCRIBE IN ITEM D. BELOW) (A.1)IS=NOT ENTER NAME OF SUBSTANCE STORED Unknown C.A.S.8: �at`V DAI rG`rr/ � III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B.AND C.AND ALL THAT APPLIES IN BOX D "✓� ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN A. TYPE OF 99 OTHER SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 1 BARE STEEL 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD Wl FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 9 ppLWINVL CHLORIDE ❑ 7 ALUMINUM ❑ B 10D% METHANOL COMPATIBLE WIFRP MATERIAL ❑ 5 CONCRETE (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANRED STEEL ❑ 95 UNKNOWN 99 OTHER 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO_ ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC D.CORROSION 96 UNKNOWN 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION O 91 NONE ❑ ❑ 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 99 OTHER B. CO=AUTOMATIC U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MU 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CU 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE WrFRP PU 9 GALVANRED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER 7 INT STITIAL 99 OTHER D. L 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ MONRORING ❑ V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR 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 3.WAS TANK FILLED WITH YES ® No❑ 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF INERTMATERIAL? Unknown SUBSTANCE REMAINING U n k n o w FIGALLONs THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME ,.�f j ,N AD � p 9/5/91 E (PRINTED A SIGNATURE) Surendra F . Pate 1 w/ %%%...JJJ^^^'� �" LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OFTHE FOUR NUMBERS BELOW COUNTY p JURISDICTION77777777;] LITY#STATE I.D.#PERMITNUMBER P RMIT APPROVED BMATE IT EXPIRATION DATE FORM B (390) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FONOGNBP4 0 % / � ii