BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA J^`��•�ue Oot' STATE WATER RESOURCES CONTROL BOARD o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION �,❑��(7 PERMANENTLY CLOSED ON SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE y�/L B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: C510 �`'� I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN '! / A OWNER'S TANK I.D.# ` B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) //�/J/L D. TANK CAPACITY IN GALLONS: I II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A. ❑ 1 MOTOR VEHICLE FUEL ❑ d OIL B. C. ❑ la REGULAR UNLEADED 3 DIESEL ❑ 6 AVIATION GAS � 2 PETROLEUM ❑ 00 EMPTY 1 PRODUCT ❑ 1p PREMIUM UNLEADED ❑ d GASAHOL ❑ 7 METHANOL //////"```"'''---------"'''�� ❑ 1t MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 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.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B,AND C,AND ALL THAT APPUES IN BOX D AND E A. TYPE OF ❑ i DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR UNER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 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 WFRP (Primary 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 LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100-A METHANOL? VES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,etc. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE VES_ NO_ STRIKER PLATE VES NO_ DISPENSER CONTAINMENT VES_ NO_ IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 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 POLYVINYL CHLORIDE(PVC)A U 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 D. LEAK DETECTION 1 MECNOMGL UNE IF.AI( O 2 UNE TIGHTNESS ❑3=M14UWS INTERS? ❑4 ELECnNJNIG UNE O 5 AUTONAnC PUMP pETECTOR TESTING MOMTORING IFAN pETELTOR SHUTpOWN ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCILIATIONANUAL INVENTORY F-13 VAOZEMONIITORING ❑ 4 GAUGING AUTOMATIC TANK ❑5 MONTORINGTER ❑6 TANUAL ESTINGTANK ❑ 7 MONITORING INTERSTITIAL ❑ B SIR ❑ 9 TANK GAUGINGAL ❑ 10 MONTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER NG VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE N-PUCE) 1.ESTIMATED DA LAST USED MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES E:] NO 001 SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.Dl m PERMIT NUMBER PERMIT APPROVED BV/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 SHOULD BE ACCOMPANIED BY A PLOT PLWE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE INGROUND STORAGE TANK REGULATIONS FORM B (6-95) 8',�il IFF(.12 GY� FOR003I11•117