BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B 1 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: GdG/ I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN A OWNER'S TANK I.D.M B. MANUFACTURED BY: G �/ C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: �� II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C, 1e REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS A ❑ 2 PETROLEUM ❑ ffa EMPTY 1 PRODUCT L—I 'b PflEMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ Ic MIDGRPDE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN E] 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOM D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: 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 r—k95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL F--] 5 CONCRETE F--] 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM E] 8 100% METHANOL COMPATIBLE W/FRP (PTMery Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING #�❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 6 UNLINED 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR O_D•EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSIONg1 NONE T!&95 UNKNOWN ❑ 99 OTHER PROTECTION ❑ s CATHODIC PROTECTION F-1 SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES_ NO DISPENSER CONTAINMENT YES_ NO E.SPILL AND OVERFILL,etc. NO_ STRIKER PLATE VES IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 UNED TRENCH ATS 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 6 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 UNKNOWN A U 99 OTHER — 1 MELHANICAI UNE LFP(( 2 UNE TIGHTNESS 3 C%INOOIIS IMFASirtIAI 4 ELECmONIC LINE 5 AUTOWnC WMP 99 OTHER D. LEAK DETECTION ❑ DETECTOR ❑ TES NG ❑ MowroBlxG ❑ LEAK oE1E'on ❑ SMITGOWN ❑ V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECOUAL NCIUATIONORY ❑ 3 MONITORING ❑ 4 GAUGNGAUTOMATIC TANK ❑5 MONTORINGTER 6 TESINGTANK ❑ 7 CONMON INUOU INTERSTITIAL ❑ 8 SIR El WANK LY MANUAL ❑10 MOTESTINGHLY TANK ❑ 95 UNKNOWN 99 OTHER ORINVI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO(DAYNR) 2.ESTIMATED QUANTITY OF O GALLONS 3 WAS TANK N FILLED WITH YES ❑ NO❑ �. SUBSTANCE REMAINING 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 8 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# m If v o y PERMIT NUMBER PERMIT APPROVED BY/DATE I PERMIT EXPIRATION DATE I6 1117 THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT POLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THEOfRGROUND STORAGE TANK REGULATIONS FORMS (6-95)