BILLING 1986-1997 - 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 ONE ITEM ❑ 2 INTERIM PERMIT 5 CHANGE OF INFORMATION ] PERMANENTLY CLOSE SIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 6 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: cy l O 7 c, I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A, OWNER'S TANK I.D.X 03 B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) 7 D. TANK CAPACITY IN GALLONS: ILTANKCONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A. ;IF((A.1) 1 MOT3 DIESEL OR VEHICLE FUEL ❑ 4 OIL B. ❑ la REGULAR o 2 PETROLEUM 60 EMPTY 1 PgODUC7 C -�/ EADED ❑ y GASAHOL ❑ 6 AVIATIONGAS 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 1b PREMIUM ❑ 5 JET FUEL ] METHANOL UNLEADED2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.x III. TANK CONSTRUCTION MARKONEITEMONLYINBOXESq,B,AND C.AND ALL THAT APPLIES IN BOX DANOE f F ❑ ,BLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER M O' ❑ ❑ 95 UNKNOWN 2 SINGLE WALL 4 SEDONOARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC AL ❑ 5 CONCRETE ❑ e POLYVINYL CHLORIDE ❑ 7 ALUMINUM ank) ❑ g BRONZE ❑ 6 100% METHANOL COMPATIBLE W/FRP ❑ 10 GALVANIZED STEEL �9s UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING 3 EPDXY LINING C.INTERIOR ❑ ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑ 6 UNLINED 5 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP PROTECTION ❑ 4 FIBERGLASS REINFORCED PLASTIC ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 5 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVE GR NO OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A PRESSURE A U 3 GRAVITY p U 99 OTHER B. CONSTRUCTION A SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH p U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL CORROSION A U A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE 5 ALUMINUM A U 6 CONCRETE PROTECTION U ] ST L W/COATING A U 6 100% METHANOL COMPATIBLE W/FRP A U 9 VANIZED STEEL p D 10 CATHODIC PRO ECTION 5 UNKNOWN D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING A U 99 OTHER V.TANK LEAK DETECTION MONRORIuc ❑99 OTHER ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING ❑ 6 TANK TESTING ❑ ] INTERSTITIAL MONITORING91 NONE ❑ ❑ 95 UNKNOWN 09 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED OUANTITV OF SUBSTANCE REMAINING 3.WAS TANK FILLED WITH ❑ GALLONS INERT MATERIAL? YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MV KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME (PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY STATE I.D.# r TANK# PERM(TNUMBER p Z 3 I 6 I C PERMIT APPROVED BV/DATE PERMIT EXPIRATION DATE _ THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORMA,UNLESS A CURRENT FORM A HAS BEEN�LED.y FORM B (12-91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS • � �� FOR11l16-q6 l