BILLING - Laserfiche WebLink

Home Browse Search

M y • �;�� Ic-61-DN )✓121->,�Ooy STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD 11 l9l0� UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B I COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. ❑ RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE MARK ONLY i NEW PERMIT 3 ❑ ONE ITEM �2 INTERIM PERMIT ❑ 4 AMENDED PERMIT /❑ 6 TEMPORARY TANnKlC�LOSURE B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN Jr' TA1CC)I rJ- B. MANUFACTURED BY: A OWNERS TANK I.D.N 7�2 _ D. TANK CAPACITY IN GALLONS: C. DATE INSTALLED(MO/OAV/YEAfl) GV IL TANK CONTENTS IF A-t IS MARKED.COMPLETE ITEM C. 6 AVIATION GAS ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. REGULAR UNLEADED 3 DIESEL ❑A PREMMM UNLEADED 4 GASAHOL ❑ 7 METHANOL 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT7':1124:b t MIDGRAOE UPIEADFD n 5 JET FUEL a MBS 3 CHEMICALPRODUCT �95 UNKNOWN ❑ 2 WAS LEADED u 99 OTHER(OESCRIBEIN ITEM D.BELOW) D. IF(At)IS NOT MARKED. ENTER NAME OF SUBSTANCE 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 I DOUBLE WALL ❑ 3- SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM 1:195 UNKNOWN A. TYPE OF r7SYSTEM � SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER �LI BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC S. TANK ❑ 9 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 9 1D0% METHANOL COMPATIBLE W/FRP MATERIAL ❑ 5 CONCRETE (Primary TERk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR95 UNKNOWN ❑ 99 OTHER B UNLINED LINING OR 5 GLASS LINING ❑ COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4FIBERGLASS REINFORCED PLASTIC CORROSION 97 NONE ❑95 UNKNOWN ❑ 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION SPILL TAINMENT INSTALLED(YEAH) QYERFlLL PflEVENITON EQUIPMENT INSTALLED(YEAR) E SPILL AND OVERFILL,eta NO_ STRIKER PLATE YES NO_ DISPENSER CONTAINMENT YES__ NO- -01, DROP TUBE YES IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U SU A U 2 PRESSURE A U 3 GRAVITY A U 4'FLEXIBLE PIPING. 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 1 B A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U a CONCRETECATHODIC PROTEC ON 7 STEEL 95/UNKNOWN A U 9910THERANOL COMPATIBLE W/FRP COATING PROTECTION A U 9 GALVANIZED STEEL A U 1 VECKIJaGu L1NE tFUL 2 LwE nmLrxESA ❑3 CWMN w1EA;m ❑4 LLECIRONC Ur& ❑5 A9r0NAnC MW ❑ 99 OTHER A� D. LEAK DETECTION ❑ oES_ " ❑ resmm Ma4ra9w0 [EAI(oETEcroR slumOwK V.TANK LEAK DETECTION 40 2 MANUAL INVENTORY ❑ 3 VADOZE LNG ❑ 4 GAUGINGC TANK ❑5 GROUP MONITORING ❑B TES71NGTANK ❑ L VISUAL CHECK ❑ RECONCILIATION MONITO9 WEEKLY MANUAL 10 MONTHLY TANK ❑ 95 UNKNOWN �9 OTHER ❑ T CONTINUOUS ONITOR U INTERSTITIAL ❑ e SIR ❑ TANK GA IN ❑ TESTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) T�[ 2.ESTIMATED QUANTITY OF ///y / 3.WAS TANK FILLED WITH YES ❑ NO 1.ESTIMATED DATE LASTU i(MO/OAYill SUBSTANCE REMAINING ��CALLONS. INERT MATERIAL 7 THIEANK ORM HAS BEEN COMPLETED UNDER PENALTY OF PERJ RY,AND 70 THE BEST OF MY KNOWLEDGE,EIS TRUE AND CORRECT DAT OWNER'S NAME /� a w AVGLIAWRE) / C LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW TANK a COUNTY It JURISDICTION it FACILITY e STATE I.D.# PERMIT EXPIRATION DATE PERMIT NUMBER PERMIT APPROVED BY/DATE ST BE THIS FORM MUSTOLD BE ACCOIMPANIED BY A PLOT PLAN. FILEFTHIS FORM WITH THE CURRENT OCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGEETANK REGULATIONS NS THIS FORM