BILLING 1994 - 2009 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA 00-2 STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM BCOMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION _J 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 0 Tlz I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.• B. MANUFACTURED BY: T SGa C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: L 000 ILTANKCONTENTS IFA-11S MARKED.COMPLETE ITEM C. A ® 1 MOTOR VEHICLE FUEL ❑ 4 OIL g, C, pl 1a REGULAR UNLEADED 3 DIESEL 6 AVIATION GAS �` ❑ 4 GASAHOL F—] 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 1bPREMIUM UNLEAD D ❑ 5 JETFUEL ❑ 7 METHANOL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF A.1)IS NOT MARKED, ENTER NAME OFSUBSTANCE STORED C.A.S.a: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX D AND A. TYPE OF ® 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 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 ❑ 8 100% METHANOL COMPATISLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER N Its, LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE e �95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) C 4 OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) I R 4 IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A672 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A 2 DOUBLE WALL A U 3 LINED 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 POLYVINYL CHLORIDE(PVC)AA 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 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 INTERSTITIAL D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING 3 MONRORING ❑99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION Ia 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO❑ SUBSTANCE REMAINING GALLONS I INERT MATERIAL? THIS FORM HAS BEEN COMP ETED U D PEN LTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAMEDATE (PRINTED 8 SIGNATURE) 4A4/ I LOCAL AGENCY USE ONLY THE STATED WARNER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# g STATE I.D.# F F717 =11 /1 z I_ PERMIT NUMBER PERMITAPPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B 112-91) / � fE FOROf 1C 96 U O/C ?q