BILLING 1985-2004 - Laserfiche WebLink

Home Browse Search

• STATE OF CALIFORNIA • s o,E STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B , I COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS 7 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK ONE REM 2 INTERIM PERMIT El REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# I' ll I A B. MANUFACTURED BY: C. DATE INSTALLED(MODAYNEAR) n. D. TANK CAPACITY IN GALLONS: I O II.TANK CONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL TI C. 18 REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS A ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ W EMPTY PRODUCT ❑ Ic MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICALPRODUCT 95 UNKNOWNWASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN REM D.BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOX D AND E ❑ 1 DOUBLE WALL F-13 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN A. TYPE OF 99 OTHER SYSTEM I�f2 SINGLE WALL F-14 SINGLE WALL IN A VAULT ❑1 BARE STEEL r72 STAINLESS STEEL E] 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK L][J MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Prim#ry Twk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED �❑ 22/ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ED GLASS LINING v o UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_)� D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION91 NONE ❑95 UNKNOWN ❑ 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION SPILL CONTAINMENT INSTALLED(Y ) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,8[C. DROP TUBE VES EA_ NO STRIKER PLATE YES_ NO C DISPENSER CONTAINMENT YES_ NO IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IFAPPUCABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING U e9 OTHER B. CONSTRUCTION U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A(01 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 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 44 1 YEEXN4CIL NNE LEV( 2 UNE R E35 ❑3 CON9NUW5 INIB6TIML ❑4 BECIRUNIC UNE ❑5 AVf01MRG PUMP�� Irl AI N D. LEAK DETECTION ❑ 9LRR�GR ❑ TEslm6 MOMTwIxG IFAN IIEiEtTOR s1G19owN V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECANUUAL IN TENTORY E] 3 VADOZEON MONITORING ❑ 4 GAUGINGAUTOMAT TANK ❑5 MON TORING WATER ❑6 TESTING ❑ 7 MONITOR CONTINUOUS INTERSTITIAL ❑ 8 SIR ❑ 9 WANK WEEKLY MGAINUAL ❑10 MONTHTES HLY TANK S 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) w 1.ESTIMATED DATE LAST USED(MOIDAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES D NO❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENAL F PERJURY, TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME �� 11 / �� DW \L DA (PRINTED 6 SIGNATURE) ,• I .( 1 - � L �l 7/ LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE R NUMBERS BELOW l/ COUNTY# JURISDICTION# r FACILITY# TANK# 00 S STATE LDAm L J I� 5115 l'),llo1T1 PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT IXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLAN. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATI lei FORME (6-95) �)I�