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. " MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE REM �z INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED f O DBA OR FACILITY NAME WHERE TANK IS INSTALLED: O103 J5, I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) ® D. TANK CAPACITY IN GALLONS: A;ko wo II.TANK PONTENTS IFA-11S MARKED,COMPLETE ITEM C. A sl 1 MOTOR VEHICLE FUEL ❑ / OIL B. C. to REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY PRODUCT 1b PREMIUM UNLEADED ❑ / GASAHOL ❑ 7 METHANOL E:] 3 CHEMICALPRODUCT El 95 UNKNOWN ❑ 2 LEADE 2 WASTE ❑ DE UNLEADED ❑ 5 JET FUEL ❑ B M85 ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOY/) 0. 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 ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER 8. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑yr�� 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR E] 5 GLASS LINING IXL 6 UNLINED El95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 10D% METHANOL] YES_ NOya D.EXTERIOR ❑ CORROSION 1 POLYETHYLENE WRAP ❑ 2 COATING E] 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECT10N�e91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,BLC. SPILL CONTAINMENT INSTALLE n R) OVEflFILL PREVENTI N UIPMENT INSTALLED(YEAR) DROPTUBE YES_ NO STpIKER PLATE YES_ NO� DISPENSER CONTAINMENT YE NO� IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE vul SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION ; Up SINGLE WALL A U 2- DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A 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 W1 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 01 MECHAHIM UNE LEAK 2 UNE TWHTNE55 ❑3 COMINUCUS NTBi5T91At ❑4 ELEc�IX11D LIME O 5 AUTCIMTC PUMP GETECIOR TESTWG MONTgiING LEAx OE1ECtt1R SHUTDOWN ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 RARE O CILATIONUAL ORY ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATGAUGNGIC TANK ❑ 5 MONITORING WATER 8 TESTINGTANK ❑ 7 MONITORING S INTERSTITIAL ❑ 8 SIR ❑ 9 WEEKLY MANUAL ❑10 MONTHLY TANK ❑ g5 UNKNOWN 99 OTHER TANK GAUGING TESTING ❑ VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED DATE LAST(1SED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3,WAS TANK FILLED WITH ; SUBSTAGE REMAINING GALLONS I INERT MATERIAL 7 YES ❑ NO ❑ 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 6 SIGNATURET LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE I.D:# COUNTY# JURISDICTION# FACILITY# TANK# YT I �-I� I-L_lJL_LJ y -711119b PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE 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 PILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE RGROUND STORAGE TANK REGULATIONS FORM B (6-95) l 6 ,y '/-_ FOg0031&RT