Laserfiche WebLink
.�/ STATE OF CALIFORNIA om <br /> STATE WATER RESOURCESCONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM BCOMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> MARK ONLY 1 PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOS <br /> ONE ITEM 2 INTERIM PERMIT O 4 AMENDED PERMIT O 6 TEMPORARY TANK CLOSURE O a TANK REMOVED O <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 7 � o1 G..pS / 4n e <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A. OWNERS TANK I.D.IF 3 B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAY/YEAR) V ^ \[_ D. TANK CAPACITY IN GALLONS: oOJ <br /> IL TANK CONTWS IFA-1 IS MARKED,COMPLETE ITEM C. <br /> 1 MOTOR VEHICLE FUEL 4 OIL B. C. 1a REGULAR n 3 DIESEL O 6 AVIATION GAS <br /> A. UNLEADED uH 4 GASAHOL <br /> O 2 PETROLEUM 0 W EMPTY PRODUCT 0 1OUNLEADED O 5 JETFUEL 7 METHANOL <br /> O 3 CHEMICALPRODUCT 95 UNKNOWN O 2 WASTE O 2 LEADED O 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> O. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C.AND ALL THAT APPLIES IN BOX D AND <br /> A. TYPE OF F-1 1 DOUBLE WALL O 3 SINGLE WALL WITH EX7ERKOR LINER O 95 UNKNOWN <br /> SYSTEMffl,--�NGLE WALL Q 4 SECONDARY CONTAINMENT (VAULTEDTANK) O 99 OTHER <br /> B. TANK O 1 BARE STEEL a 2 STAINLESS STEEL 0 3 FIBERGLASS 0 4 STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL O S CONCRETE O B POLYVINYL CHLORIDE O 7 ALUMINUM O 8 100% METHANOL COMPATIBLE W/FRP <br /> (PrimaryTwk) O 9 BRONZE O 10 GALVANIZED STEEL 5 UNKNOWN O 99 OTHER <br /> O 1 RUBBER LINED O 2 ALKYD LINING Q 3 EPDXY LINING O 4 PHENOLIC LINING <br /> C.INTERIOR O 5 GLASS LINING O 6 UNLINED �OFKNOWN 0 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 10C%METHANOL? YES_ NO- <br /> D.CORROSION F-] 1 POLYETHYLENE WRAP = 2 COATING O 3 VINY WRAP O 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION = 5 CATHODIC PROTECTION 091 NONE UNKNOWN O 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE <br /> A. SYSTEM TYPE Ao SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION ArP UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION E] I AUTOMATIC LINE LEAK DETECTOR L.-C "'•E TIGHTNESS TESTING E-] 3MONRORING 0 99 OTHER <br /> V.TANK LEAK DETECTION <br /> O 1 VISUAL CHECK 2 INVENTORY RECONCILIATION 0 3 VADOZE MONITORING O 4 AUTOMATIC TANK GAUGING 0 5 GROUND WATER MONITORING <br /> O 6 TANK TESTING O 7 INTERSTITIAL MONITORING O 91 NONE 95 UNKNOWN O 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES 0 NOE:] <br /> SUBSTANCE REMAINING GALLONS INERTMATERIAL7 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME DATE <br /> (PRINTED 8 SIGNATURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY It TANK If <br /> STATE I.D.# cc I 4;r-2. <br /> PERMITNUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE (/ <br /> THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. �rJ/( <br /> FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS 70- <br /> FORM B 112-911 � �f j0-/ x FOPOON6N6 <br /> JS ) <br />