Laserfiche WebLink
STATE OF CALIFORNIA .p U <br /> STATE WATER RESOURCES CONTROL BOARD w Wit'' <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br /> 'C4llFp P'N�, <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> EDBA <br /> ;FACILITY <br /> ;N�AME <br /> NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED O TE <br /> INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 0 B TANK REMOVED <br /> WHERE TANK IS INSTALLED: S <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.# B. MANUFACTURED BY: ✓h� <br /> C. DATE INSTALLED(MOIDAYIYEAR) n D. TANK CAPACITY IN GALLONS: <br /> ILTANKCO NTS IFA-1_IS MARKED,COMPLETE ITEM C. <br /> 1a REGULAR 3 DIESEL 6 AVIATION GAS <br /> A 1 MOTOR VEHICLE FUEL � 4 OIL B. C. UNLEADED 4 GASAHOL <br /> BeEMPTY 1 PRODUCT Ib PREMIUM 7 METHANOL <br /> 2 PETROLEUM UNLEADED 5 JET FUEL <br /> 3 CHEMICAL PRODUCT F--] 95 UNKNOWN 2 WASTE 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW} <br /> D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.x: <br /> 1h, TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.9,AND C,AND ALL THAT APPLIES IN BOX D <br /> 1-1 1 DOUBLE WALL D 3 SINGLE WALL WITH EXTERIOR LINER Q 95 UNKNOWN <br /> A. TYPE OF <br /> SYSTEM INGLE WALL El El 99 OTHER 4 SECONDARY CONTAINMENT (VAULTEDTANK) <br /> IBARE STEEL F7 2 STAINLESS STEEL ❑ 3 FIBERGLASS O 4 STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC <br /> B. TANK 7 6 POLYVINYL CHLORIDE 7 ALUMINUM 8 100/ METHANOL COMPATIBLEWIFRP <br /> MATERIAL 5 CONCRETE <br /> (PrimaryTank) 9 BRONZE El 10 GALVANIZED STEEL 95 UNKNOWN E:] 99 OTHER <br /> 1 RUBBER LINED F--1 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR 5 GLASS LINING 0 6 UNLINED NKNOWN 99 OTHER <br /> LINING I� <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— <br /> D.CORROSION <br /> I POLYETHYLENE WRAP ❑ 2 COATING E] 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> 0 <br /> PROTECTION � 5 CATHODIC PROTECTION a 91 NONE 99 OTHER <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL COATING A U 8 140°/ METHANOL COMPATIBLE W1FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A 95 NKNOWN A U 99 OTHER <br /> 1 AUTOMATIC LINE LEAK DETEC*� 9INTERSTITIAL 99 OTHER <br /> D. LEAK DETECTION Q R LINE TIGHTNESS TESTING MONITORING <br /> V.TANK LEAK DETECTION <br /> 1 VISUAL CHECK ,�TNVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING F7 4 AUTOMATIC TANK GAUGdNG 5 GROUND WATER MONITORING <br /> L s TANK TESTING 7 INTERSTITIAL MONITORING 91 NONE E� 95 UNKNOWN 99 OTHER <br /> VI,TANK CLOSURE INFORMATION <br /> --F2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> 1.ESTIMATEd DATE LAST USED(MOIDAYlYR) SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME DATE <br /> (PRINTED&SIGNATURE( <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK# �S 7,V'12 <br /> STATE {.D.# � I - 2- 7 0 <br /> PERMITNUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE <br /> FORM R (9-91)) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. f <br /> 1`0116034B�R4 <br /> c <br />