BILLING 1985-1999 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA } / o STATE WATER RESOURCES CONTROL BOARD W., UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. 4004 MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑ 9 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D. B. MANUFACTURED BY: C. DATE INSTALLED(MOIOAYNEAR) D. TANK CAPACITY IN GALLONS: 11.TANKCONTENTS IFA-11SMARKED,COMPLETE ITEM C. 1a REGULAR ❑ 3 DIESEL ❑ 6 AVIATiONGAS A F�1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C UNLEADED 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT 1 bPREMIUM AD D ❑ 5 JET FUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. iF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED ©r C.A.S. Q (✓L. III, TANK CONSTRUCTION MARK O ITEM ONLY IN BOXES A,B.AND C,AND ALL THAT APPLIES IN BOX D AND E ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN A. TYPE OF 99 OTHER SYSTEM ❑ 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 1 BARE STEEL ❑ STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W1 FIBERGLASS REINFORCED PLASTIC H. TANK5 CONCRETE ❑ 6 LYVINYL CHLORIDE ❑� 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WIFRP MATERIAL ❑ (Primary Tank) ❑ 9 BRONZE ❑ 10 GA ANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ i RUBBER LINED ❑ 2 ALKYD L INC ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL YES_ NO_ ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC D.CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION F795 UNKNOWN 99 OTHER 91 NONE ❑ E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) VERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVY A U 99 OTHER B. CONSTRUCTION A U t SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TR H A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CH RIDE(PVC)A U 4 FIBERGLASS PIPE CONCRETE A U 7 STEEL WI COATIN A U 8 100% METHANOL COMPATIBLE WIFRP CORROSION A U 5 ALUMINUM A U 6 PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN N., A U 99 OTHER__ IL D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR [:] 2 LINE TIGHTNESS TESTING E] 3 MDN T{S I fs ❑ OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGIN`G ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO 1.FSTIMAT D E T USED(MOIDAYIYR) SUBSTANCE REMAINING GALLONS INERT MATERIAL? —- THIS F RM HAS BFEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT DATE APPLICANTS NAME (PRINTED a SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# FT [I C 3 PERMIT NUMBER PERMIT APPROVED BYlDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH' OCAL AGENCY IMPLEMENTING THE UNDERGROUND ST GE TANK REGULATIONS FORMS (12-91) ch m RJI q--�7`ir FOR= I 11f