BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA �• °O: 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 CLOSEDON�ITE_ ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: p�pY I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNER'S TANK I.D.It -5 B. MANUFACTURED BY: u S C O C. DATE INSTALLED(MOIDAYNEAR) 9600 D. TANK CAPACITY IN GALLONS: / 0, 4000 II.TANK CONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B.1.��I' C. ❑ 1, REGULAR UNLEADED DIESEL ❑ 6 AVIATION GAS EMIUM NLEADED A ❑ 2 PETROLEUM ❑ BO EMPTY Rt PRODUCT O is MIRDGRADEVUNLEADED ❑ 5 ET FUEL ❑ 8 M85 METHANOL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN C. 2 WASTE ❑ 2 LEADED ❑ 99 OTHER IDESCRIBE IN ITEM D.BELOVO D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.R: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX AND A. TYPE OF I DOUBLE WALL F-13 SINGLE WALL WITH EXTERIOR UNER E::] 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL F-14 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 1001/6 METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ,❑ 2 ALKYD LINING ❑ 3 EPDXY LINING E—] 4 PHENOLIC LINING LINING OR ❑ X 5 GLASS LINING 8 UNLINED ❑ 95 UNKNOWN 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES NO_ 1� 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(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,BSC. 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 SUCTION A 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 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 8 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 NEGNANICAL LINE LEAK 2 UNE IWMNE55 CONTINGWS INTERST0IAL ❑1 EU:CmONIC UNE O 5 AUfGM4TG PDMP 99 OTHER ttG DETECTOR TESTING M04TMM LEAK DETE'on SHumowN V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCILIIATONORY ❑ 3 MAONNIITORING ❑ 4 AUTOMATGA GN IC TANK ❑ 5 GROUND MONITORING TESTING❑6 TESTINGTANK 7 CONTINUOUS INTERSTITIAL ❑ B SIR ❑ 9 WE K LY MANUAL ❑10 M SNTITFNILY TANK ❑ 95 UNKNOWN ❑99 OTHER MONITORING VI,TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMAXY GATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO[] SUBSTANCE REMAINING GALLONS INERT MATERIAL? 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 a SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW I�12 ( 3 O COUNTY# JURISDICTION A FACILITY R �- -�T--ANK% STATE I.D.# m VL" Q 4 U PERMIT NUMBER PERMIT APPROVED BY/DATE 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 FORM B (6.95 3 SHOULD BE ACCOMPANIED BY A PLOT PULE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE GROUND STORAGE TANK REGULATI I _ 9 II��SSjj 99YY�1'-