BILLING - Laserfiche WebLink

Home Browse Search

/I Islip-( 1CB• ,o�13iD y ,ti�ti STATEOFCAUFORNIA STATE.WATER RESOURCES CONTROL BOARD FORM B UNDERGROUND STORAGE TANK PERMIT APPLICATION - `>. 1tl COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY �7 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM 2 INTERIM PERMIT ❑ d AMENDED PERMIT /❑ 8 TEMPORARY TANKCLOSUREB TANK REMOVED DBA OR FACILITY NAME WHERE TANK I5 INSTALLED: Lo /"/�. `5 23 A 8 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN p OWNERS TANK I.D.R 1 I r JC S /-TB. MANUFACTURED BY: C. GATE INSTALLED(MOIDAYIYEAR) D. TANK CAPACITY INGALLONS: q D II.TANK CONTENTS IF A-3 IS MARKED.COMPLETE ITEM C. 8 AVIATION GAS F-1 7 MOTOR VEHICLE FUEL ❑ d OIL B. C. 14 PEGULM UNLEADED 3 DIESEL ❑ A 1R PREMIUM UNLEADED 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ B0 EMPTY ❑ I PRODUCT Ic MIDGRADE UNLEADED 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICALPRODUCT c;z95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 OTHER(DESCRIBE INREIAO.BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.k: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C.AND ALL THAT APPLIES IN SOX,D AND E OF ❑)i DOUBLE WALL ❑ 3' SINGLE WALL WITH EXTERIOR LINER E:] 5 INTERNAL.BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM i SINGLE WALL A. TYP ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK � BARE STEEL F-12 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W1 FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 5 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WiFRP (PrimaryTEnk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR F7 ❑ 8 UNLINED x[95 UNKNOWN ❑ 99 OTHER LINING OR F-15 GLASS UNINO , COATING IS LINING MATERIAL COMPATIBLE WITH 10D% METHANOL? YES— NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4FIBERGLASS REINFORCED PLASTIC CORROSION 91 NONE ❑95 UNKNOWN ❑ 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTIO$ _ SPILL CONTAINMENTINSTALLED(YEAR) YEAFlLL PREVENTION EQUIPMENTDISPENSER CONTAINMENT YES_ NO E SPILL AND OVERFILL,BTa. DROP TUBE YES— NO_ STRIKER PLATE YES__ NO_ IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IFUNDERGROUND,BOTH IFAPPUCABLE A. SYSTEM TYPE A U SUC A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLEPIPING. A U 99 OTHER B. CONSTRUCTION A U SINGLE'WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U I BAR A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE IPVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U B CONCRETE A U 7 STEEL WI COATING A U 8 100Ys METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER C 1 MECKYEGI UJI 1F/Jt 2 AWE TCMtFSS [:]3 WERSTML ❑!BECTBOMC LWE ❑5 AVTGWnc mw 99 OIHFA ^/ � D. LEAK DETECTION ❑ oElEaoR C:] TEmBG L K IIETECTDR muiooxw V.TANK LEAK DETECTION 2 MANUAL INVENTORY ❑ 3.MAODNOITORIN6 ❑ 4 GAUGG AUTOMATIC TANK ❑ 5 GROUND MONITORING TESTING ❑e TTEESTINGTANK ❑ I VISUAL CHECK ❑ RECONCILIATION 7 CONTINUO US INTERSTITIAL ❑ 8 BIR ❑ 97WpryK GAUGINGAL ❑10 To nNGMONTHLY TANK ❑ 95 UNKNOWN OTHER ❑ MONITORING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) r� 2 ESTIMATED QUANTITY OF � ONS 3.W INERTMATERIAAS TANK FILLED L?TH YES ❑ NO �C 1 ESTIMATED DATE LAST USF?D(M0/DAYA'R) SUBSTANCE REMAINING THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJ RY,AND TO TH�OBESTI MYKNOWLEDGE,EIS TRUE AND CORRECT TANK OWNER'S NAME / 0 (PRPRE0A 9GNANPE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTYR JURISDICTION 4 FACILITY N TANK M STATE I.D.A m PERMIT APPROVED SYMATE PERMIT EXPIRATION DATE PERMIT NUMBER THIS FORM MUSTSHOULD BE ACCOMPANIED BY A BY PERMIT APPLICATION-LOT PLAN. FILEETHIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS THIS FOR