BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD �� '`SOLA UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B "� = COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. " MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT4 AMENDED PERMIT 8 TEMPORARY TANK CLOSURE ❑ ❑ B TANK REMOVED -- EMOVED6�1 cf DBA OR FACILITY NAME WHERE TANK IS INSTALLED: e vfa 4 E } t , r /a l 3 Cl I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNERS TANK I.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A JZ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1e REGULAR UNLEADED ❑ 3 DIESEL ❑ 8 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT ❑ Ib PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ED CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE Ic MXIGRADE UNLEADED ❑ 5 JET FUEL ❑ B M85 ❑ 2 LEADED ❑ S9 OTHER(DESCRIBE M ITEM D.BELOW) D. IF(AI)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 D AND E A. TYPE OF ❑I� i DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR UNER ED INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM I�i�' 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK LXI I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL /❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PdMoy Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER UNED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING 8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR I POLYETHYLENE WRAP2 COATING CORROSION ❑ ❑ ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,BTO. 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 APPUCABLE A. SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLEPIPING A U 99 OTHER B. CONSTRUCTION KD I SINGLE WALL A U 2 DOUBLE WALL A U 3 UNED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND 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 8 CONCRETE A U 7 STEELW/COATING A U B 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 89 OTHER D. LEAK DETECTION ❑I �cxuncu ml IEAII �2 LNE TIGNn % ❑3 w NVWS IIVIDI6nIL4L 4 ELEcrRaxlc uMs s Auro6unc Puw OETEGTOR IESI9q I OPWG ❑ lE1N OEIEC U ❑ A=nC ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCILIATION ❑ ❑ MNUALINVENTORY ❑ 3 V ❑ 4TOC TANK O5 GROUND RRO DWTER ❑ 8 ANNTANK 7NOUS INTERSTITIAL AMONITORING GAUGING MONITORING TESTING MOTORF, B SIR ❑ 9 WEEKLY MANjUUAL ❑10 MONTHLY TANK ❑ 95 UNKNOWN ❑TING99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN.PLACE) 1.ESTIMATED DATE LAST USED(M AY/YR) 2.ESTIMATED UANTTTY OF �rny-� 3.WAS TANK FILLED WITH �ti(, SUBSTANCE REMAINING ERIAL 7 YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER P PFPERJURY,AND T96 THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT E RINTED B SIGNATURE) I DATE p,LLPc Ivt � �f Pr �Guyt2r I?i 21 Q LOCAL AGENCY USE ONLY THE STATE I.D.NUMB IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY#,3 O TANK# j�.2 STATE I.D:# m F—F—F] z 3 y 9 PERMIT NUMBER PERMIT APPROVED BVADATE PERMIT EXPIRATION DATE _ Gj L{ 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 PLA LE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UWGROUND STORAGEREGULATIONS FORM B (8-95) 55 3