BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA • '�So""�s r STATE WATER RESOURCES CONTROL BOARD 'g UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B "�d� COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED O ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED ) DBA OR FACILITY NAME WHERE TANK IS INSTALLED: as/ T - I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# B. MANUFACTURED BY: SC D C. DATE INSTALLED(MO/DAWVEAR) D. TANK CAPACITY IN GALLONS: D -)0 El II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A �1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ is REGULU UNLEADED ❑ 3 DIESEL ❑ 8 AVIATION GAS 1YY❑---"" 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 1e MIDGRADE UNLEADED ❑ 5 JETFUEL ❑ 8 M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE vr 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOM D. IF(At)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B AND C,AND ALL THAT APPLIES IN BOX AND A. TYPE OF 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL O 3 FIBERGLASS 4 STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM 111111��❑ 8 100% METHANOL COMPATIBLE W/FRP (PHmary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN 99 OTHER C.INTERIOR ❑ 1 RUBBER UNED `�❑ ❑2 ALKYD LINING 3 EPDXY UNING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ul 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLES WITH 100% METHANOL? YES NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 'X4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION E] 91 NONE ❑95 UNKNOWN 99 OTHER E.SPILL AND OVERFILL,Bic. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) 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 ACU> SUCTION XMI2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U)95 UNKNOWN A U 99 OTHER C. MATERIALAND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLWINYL 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 D. LEAK DETECTION / !Ai H CAL(INE:] E LP 2 UNE TM,H1NEM 3 CONnNUWS IMBiST 4 EIFCTRONIC UNE 5 AVOWTIC PUMP ❑ DETECTOR TESTING ❑ MONTORING ❑ IEW OEIECTOR ❑ GHUTGOWN 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL RECONCILIATION ❑ 3 VAOZEMONIITORING ❑ 4 GAUGINGAUTOMATIMONITORING TANK ❑ 5 GROUND MONTORING�R ANNUALTANK ❑6 TESTING 7 MONITORU INTERSTITIAL ❑ 8 SIR E:] 9 WE K LY MANUAL O 10 MOTESTINGHLY TANK ❑ 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FlLLED WITH YES NO❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTED B SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW p{2, d.J 13 G COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D:# am Fm 1113161411 PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A 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 REGULATIONS FORM (6.95) '3-„ 'TO1 5.r4z"(A"/{J►4#'�` I o 7"/a/ '� O�