BILLING 1985-2004 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA P4 s oo' s STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B 1 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 7 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ON SI ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED A+� DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I ll I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNER'S TANK I.D.4 / B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAV/YEAR) D. TANK CAPACITY IN GALLONS: /O 000 II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. ❑ 1a flEGUUR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B.�—�/ C. ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ 80 EMPTY I 1 PRODUCT ❑ 1c MIDGRADE UNLEADED ❑ 5 JETFUEL ❑ 8 M85 ❑ 3 CHEMICALPRODUCT ❑ 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 C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C.AND ALL THAT APPLIES IN BOX 0 AND E F—] I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN A. TYPE OF SYSTEM 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT 11 99 OTHER 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE E::] 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY UNING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNO��W[[N 99 OTHER ❑ COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NOLO D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION91 NONE ❑95 UNKNOWN El 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION ❑ SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EOUI PMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,BIC. DROP TUBE YES_ NO_ STRIKER PLATE YES_ NO_ DISPENSER CONTAINMENT YES_ NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLEPIPING A U 99 OTHER B. CONSTRUCTION A SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A V 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U S ALUMINUM A U 6 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 i MECWWICAL UNE LEAN 2 UNE TIGHTNESS 3 CONTINUWS INTFRSTINA d FLEC7110NIC UNE 5 AMOWTIC PUMP 99 OTHER D. LEAK DETECTION ❑ DETECTOR TESTING ❑ MGNRONING ❑ LEAN=cTGR ❑ SH 0I 511 ❑ V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 RECNUAL ONCILIATIONORV ❑ 3 VAOZE MONIITORING E] 4 GAUGINGAUTOMATI TANK ❑ 5 MONTORINGGROUND TER 6 TESTINGTANK ❑ 7 MON TOR U INTERSTITIAL 8 SIR ❑ 9 TIANEKLY K GAUGINGAL E]10 TMESiMINGV TANK O 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE USED V R) 2.ESTIMATED QUANTITY OF 3.WAS TANK RLLED WITH YES ❑ NO _ ✓ SUBSTANCE REMAINING GALLONS I INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT DATE TANK OWNER'S NAME (PRINTED 6 SIGNANRE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION M FACILITY#019,S" �, ' TANK#� STATE I.D.# = [Z3 ! 3 0 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE s-/ THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED OR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT P FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THERGROUND STORAGE T^ REGULATIONS 12 FORM B (6.95) 14, ,✓0/)7 O'1 A�1—1 ,J,�1Q