BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B "� w COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION S ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT 7 PERMANENTLY CLOSED ONS ❑ ❑ 6 TEMPORARY TANK CLOSURE 4z IB TANK REMOVED �) DBA OR FACILITY NAME WHERE TANK IS INSTALLED: t r4 I P LJ 3 ,_, D S C I. TANK DESCRIPTION I COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.• ,. B. MANUFACTURED BY: (�. C. DATE INSTALLED(MOA)AYNEAR) U D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IFA.IISMARKED,COMPLETE ITEM C. A. m 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. 1a REGULAp UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT 16 PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ l0 MIDGRADE UNLEADED ❑ 5 JETFUEL ❑ 8 M85 ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE INITEMD.BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.S.AND C.AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM SYSTEM 2 SINGLE WALL ❑ [1 85 UNKNOWN 4 SINGLE WALL IN A VAULT ❑ 89 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 ❑ 8 100% METHANOL COMPATIBLE W/FRP (PdRMly Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS UNING 8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ D.ERASION OR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,etc. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENOON EQUIPMENT INSTALLED(YEAR) DROP TUBE VES_ 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 U 1 SUCTION q U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER S. CONSTRUCTION AL 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(9,4 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 STEELW/COATING PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U B 100% METHANOL COMPATIBLE W/FRP A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑1 MECxN4Gu UK" ❑2 Ma:TIGXIx95R ❑3 coxnxuws uRBs1 4 EIECDWMC USE 5 AuroMAnc RUMR DETECTOR TESINn YONTgIN6 [fAX 9En:CfOP SIxR TC ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL I INVENTORY ❑ 3 VADOZE IATION ❑ 4 AUTOMATIC TANK 5 GROUND WATER 8 ANNUAL TANK ! ❑ 7 CONTINUOUS INTERSTITIAL RECONCMONITORING GAUGING ❑ MONITORING ❑ TESTING MONITORING ❑ B SIR ❑ 9 ANEK GAL ❑ 10 TESTINGLY TANK ❑ 85 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAE"SR YSED ICM0/pgy/yR) 2.ESTIMATED QUANTITY OF �� 3.WAS K FILLED WITH L !/� ( JK NCE REMAINING GALLONS INERT MATERIAL 7 YES ❑ NO'�ff THIS FORM HAS BEEN COMPLETED UNDER PENA OF ERJURY,AND TO THE BE T OF MY KNOWLEDGE,IS TR E AN CORRECT TANK OWNER'S NAME _ ((77__ DATE 12. 2qK LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW /Cc G. ZD oZ.3 COUNT y STATE LD:# M JURISDICTION M FACILITY k TA �J�TYJ�JT 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 FORME (8-95)SHOULD BE ACCOMPANIED BY A PLOT PLJjgE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UISGROUND STORAGE TANK REGULATIONS