BILLING_1988-1999 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. 1 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ON SITE ONE REM ❑ 2 INTERIM PERMIT ❑ < 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.1:1 B. MANUFACTURED BV: C. DATE INSTALLED(MO/DAY/YEAR) (�. D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS F A-1 IS MARKED,COMPLETE ITEM C. A ❑ 1 MOTOR VEHICLE FUEL ❑ A OIL B. C. 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 8 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT /b PREMIUM UNLEADED ❑ d GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 1c MIDGMDE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE M ITEM D.BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OFSUBSTANCE STORED C.A.S.N 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 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ A SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK 1 -BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ A STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary A91) ❑ B BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ q PHENOLIC LINING LINING OR ❑ 5 GLASS LINING �6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL 7 YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING CORROSION ❑ 3.VINYL WRAP ❑ 1 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTFCTIONIL191 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,6ID. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENRON EQUIPMENT INSTALLED(YEAR) DROP TUBE YES NO STRIKER PLATE VES_ NO_ DISPENSERCONTAINMENTYES_ 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 A FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A 1 SINGLE WALL A U 2 DOUBLE WALLA U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A(! UNKNOWN A U 99 OTHER STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 6 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 A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION t � '"�LINE OF ❑2 UNE ipMNE56 ❑3 CgrtIM1GU3 WIEASIRi1l O 4 E1ECmgVIC UNE ❑5 AAW�nC Pulmo O 99 OTHER OE1ECrOR TES11N6 MONi0.91N6 IFN DETECTOR V.TANK LEAK DETECTION ❑ ] CISUAL CHECK ONTINUOUS INTERSTITIAL ❑ 2 MANUAL RECONCILIATIONMONITORING ❑ 3 MONIITORING OZE ❑ L AUTOMATGAUGING TANK ❑ 5 MONITORING GROUND TER ❑ e TESTIANNUAL NK MONITORING ❑ B SIR ❑ 9 WEEK LY MANUAL ❑10 MONTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER TANNG VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED DAT Tj16ED701DAY 2.ESTIMATED QUANTITY OF � 3.WAS TANK FILLED WITH J / ! SUBSTANCE REMAININGGALLONS INERT MATERIAL 7 TANK OWNER'S NAME YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDEFj P OF RJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT _ (PRINTED f.SIGNATURE),, �k � LOCAL AGENCY USE ONLY THE STATE LD.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW t �/ 6�A{ STATE ILD:# COUNTY a JURISDICTION A FACILITY k TA ,F L--`--L!—I_ILJJ �-� IT PERMIT NUMBER PERMIT APPROVED BYIDATE �-- PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM FORM B (695)SHOULD BE ACCOMPANIED BY A PLOT PLWLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE JWGROUND STORAGE T R GULATIONS /3- �