BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD j 1 I k I�✓I su'�� a UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY NEW PERMIT ❑ 3 RENEWAL PERMT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK�CCLOSURE n✓n B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 40 PR iJ a3 a FI I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D. /_ I B. MANUFACTURED BY: C DATE INSTALLED(MQIDAY/YEAR) - K D. TANK CAPACITY IN GALLONS: C 7L. II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. 1 MOTOR VEHICLE FUEL E:] 4 OIL B. C. 1a REGULAR UNLEADED 3 DIESEL ❑ 6 AVIATION GAS A ❑ 1b PREMIUM UNLEADED g 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ i PRODUCT 1e MIDGRAOE UNLEADED ❑ 5 JET FUEL ❑ 8 1485 ❑ 3 CHEMICALPRODUCT 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN Two.BELom D. IF(A7)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED 4 C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C,AND ALL THATAPPLIES IN BOX D AND E A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR UNER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM �2 SINGLE WALL ❑ d SINGLE WALL IN A VAULT ❑ 99 OTHER BARE STEEL F-] 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ ] ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER UNED ❑ 2 ALKYD LINING ❑ 3 EPDXY UNING ❑ 4 PHENOLIC LINING C.INTERIOR �95 UNKNOWN ❑ 99 OTHER LINING OR ❑ 5 GLASS UNING ❑ 8 UNUNED COATING IS UNING MATERIAL COMPATIBLE WITH 10D% METHANOL? YES— NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4FIBERGLASS REINFORCED PLASTIC CORROSION 91 ❑ 95 UNKNOWN ❑ 99 OTHER PROTECTION F75 CATHODIC PROTECTIOKJ�. NONE SPOPILL CONO DISPENSER CONTAINMENT YES NTAINMENT INSTALLED(YEAR) OVERFlLL PREVENTION EQUIPMENT INSTALLED(YEAR) E SPILL AND OVERFILL,Bic. DRTUBE YES_ NO_ STRIKER PWTE YES_ _ _ NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U SLAC A U 2 PRESSURE A U 3 GRAVITY A U A. FLEXIBLE PIPING. A U 99 OTHER B. CONSTRUCTION A U SING LE..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 BRE A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 1 ALUMINUM A U 8 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 ��,11nnnn CC 1 MECNAMCAL UNE LEAK 2 UNE TWHO.ESS ❑3 CG AKIIJS INTERS ❑4 ELECM041C UNE ❑5 AVTOMAPC PUMP C::] 99 OTHER �ry D. LEAK DETECTION ❑ OETEMOA ❑ MSnaa MGMTCRNG LTAK)MCTOR sHurOoxm Vr7E] 7 TANK LEAK DETECTION VISUAL CHECK 2MANUAL(INVENTORY ❑ 3 IATION MONRORING 4 GAUGAUTOING C TANK ❑ 5 MON TORINGGROUND TER ❑ e TESTINGANNUALRECONCTANK MON CONTINUO G US INTERSTITIAL ❑ 8 SIR F-19 WEEKLY MANUAL ❑10 MO TTHHLY TANK 1--] 95 UNKNOWN .� OTHER VI,TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) SUBSTANCE REMAINING 3.WAS ERT MATERIAL? YES ❑ NO®C 1.ESTIMATED DATE LAST UU��(MO/DAY/YR) SUBSTANCE REMAINING �"•+ALLONS INERT MATERIAL 1 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJ RY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME (PpWTED 6510NANRE) � ,C /� LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY It TANK# STATE I.D.# m PERMIT NUMBER PERMIT APPROVED BV/GATE PERMIT EXPIRATION DATE FOR THIS FORM MUSTSHOULD BE ACCOMPANIED BY A(PLOT PLAN. FILEFORM THIS FORM WITH THE A.UNLESS A LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORA EFORM A HAS BEEN FILED. FORM C MUST BE E ANK REGULATIONS THIS FORM FORM B (8.951