Laserfiche WebLink
.. law <br /> ee W��le <br /> STATE OF CALIFORNIA `.. <br /> STATE WATER RESOURCES CONTROL BOARD y _. e <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br /> gid: <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY O 1 NEW PERMIT O 3 RENEWAL PERMIT ® 5 CHANGE OF INFORMATION O T PERMANENTLY CLOSED <br /> ONE ITEM O 2 INTERIM PERMIT F-1 4 AMENDED PERMIT O 6 TEMPORARY TANK CLOSURE O 8 TANK REMOVED O <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: e-- gc>r4 ST/3TI0 t.1 --2w 9- I a¢8 <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN ZS W J..� It <br /> A OWNERS TANK I.D.♦ 3 S. MANUFACTURED BY: OWFSOJS <br /> C. DATE INSTALLED(MO/DAYNEAR) 'g'7' -7 - -9 1 D. TANK CAPACITY IN GALLONS: 2 �� <br /> II.TANK CONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. <br /> A. Cg 1 MOTOR VEHICLE FUEL O 4 OIL B. C. Ia REGULAR UNLEADED 3 DIESEL O 6 AVIATION GAS <br /> O 2 PETROLEUM O 80 EMPTY 1 PRODUCT tb PREMIUM UNLEADED 4 GASAHOL ED T METHANOL <br /> ® 1C MIDGRADE UNLEADED O 5 JET FUEL a 8 MBS <br /> 3 CHEMICALPRODUCT O 95 UNKNOWN EJ 2 WASTE ❑ 2 LEADED ❑ 99 01HER(DESCRIBEINITEM0.8ELOW) <br /> D. IF(At)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: C::;k�eVG 19 <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C,AND ALL THAT APPLIES IN BOX D AND E <br /> A. TYPE OF 1 DOUBLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER a 5 INTERNAL BLADDER SYSTEM a 95 UNKNOWN <br /> SYSTEM Q 2 SINGLE WALL Q 4 SINGLE WALL IN A VAULT Q 99 OTHER <br /> B. TANK I BARE STEEL O 2 STAINLESS STEEL ® 3 FIBERGLASS O 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL O 5 CONCRETE O 6 POLYVINYL CHLORIDE F-� T ALUMINUM O 8 100% METHANOL COMPATIBLE W/FRP <br /> (PHmary T#Dk) 9 BRONZE O 10 GALVANIZED STEEL [1] 95 UNKNOWN 0 99 OTHER <br /> C.INTERIOR F-1 I RUBBER LINED Q 2 ALKYD LINING O 3 EPDXY LINING 4 PHENOLIC LINING <br /> LINING OR ❑ 5 GLASS LINING ® 6 UNLINED ❑ 95 UNKNOWN 0 99 OTHER <br /> COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? VES x NO— <br /> D.EXTERIOR 1 POLYETHYLENE WRAP O 2 COATING ❑ 3 VINYL WRAP ® 4 FIBERGLASS REINFORCED PLASTIC <br /> CORROSION <br /> PROTECTION 5 CATHODIC PROTECTION Q 91 NONE O 95 UNKNOWN El <br /> 99 OTHER <br /> E.SPILL AND OVERFILL,BIC. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL fREVENTION EQUIPMENT INSTALLED(YEAR) <br /> DROP TUBE YES NO_ STRIKER PLATE YES�_ NO_ DISPENSER CONTAINMENT VES NO <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION Aig 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL A6)2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A(1)4 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U T STEEL W/COATING A U 6 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER <br /> 1 N =L UNE LEAK TIGI KM T'pI 3 CCNTIMX U6 NTFRSTRELL X 4 ELECTRO K UNE 5 AM""nc NW <br /> D. LEAK DETECTION O MIi BETEOTCR O 2 ME TESTING V� MOHTORNG LFAK GETECTOR ® SNU10pwx BB OTNER <br /> V.TANK LEAK DETECTION <br /> Q 1 VISUAL CHECK 2 RECONCILIATIONNUAL ORV 0 3 MAODNIITORING OZE ® 4 GAUGING AUTOMATIC TANKE] 5 MONITORING GROUND TER O 6 ANNUALTESTINGTANK <br /> T COMON TOR U INTERSTITIAL 0 8 SIR 09 <br /> WE KL MANUAL O 10 MOTESTINGHLY TANK O 95 UNKNOWN O 99 OTHER <br /> VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) <br /> 1.ESTIMATED DATE LAST USED(MOADAYNFI) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES 0 NO <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL? <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> TANK OWNER'S NAME n DATE o <br /> (PRWTEO#61GNATURE) oe <br /> LOCAL AGENCY USE ONLY l THE STATE I.D.NUMBER IS COMPOSED OF OUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# I TANK# 009 <br /> STATE I.D.# m 6 L3110 <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE <br /> THIS FORM MUST BE ACCOMPANIED BY A PERMIT API TION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED IM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM <br /> SHOULD BE ACCOMPANIED BY A P^LOI�f!. RLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING 1,w IDERGROUND STORAGE TANK REGULATIONS <br /> FORM B 16-951 I�/Z L /pQ <br />