REMOVAL_1995 - Laserfiche WebLink

Home Browse Search

0 00 ce Fk F t STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD w,a � . Ic v UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE MARK ONLY ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: '� EI �N I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK 1.D.K B. MANUFACTURED BY: V AJ K/ r O C. DATE INSTALLED(MOIDAYNEAR) U� fL! D. TANK CAPACITY IN GALLONS: 8 ILTANKCONTENTS IFA-1IS MARKED,COMPLETE ITEM C. 1a REGULAR 3 DIESEL 6 AVIATION GAS A ❑ 1 M070R VEHICLE FUEL ❑ 4 OIL B. C. 4!!� UNLEADED 4 GASAHOL ❑ 80 EMPTY ❑ 1 PRODUCT ❑ 1EUNLEAUM ❑ ❑ 7 METHANOL ❑ 2 PETROLEUM 5 JETFUEL ❑ 3 CHEMIGAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.X: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX D AND E ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN A. TYPE OF 99 OTHER SYSTEM ❑ 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ i BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W!FIBERGLASS REINFORCED PLASTIC B. TANK 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100>d METHANOL COMPATIBLE WlFRP MATERIAL ❑ (Primary Tank) ❑ 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 ❑ 94 OTHER LINING c IS LINING MATERIAL COMPATIBLE WITH 10D% METHANOL? YES_ NO� ❑ 1 POLYETHYLENE WRAP F—] 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC D.CORROSION ❑ PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR)V� w� OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) d,Qu 1 h1 IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE A, SYSTEM TYPE A U 1 SUCTION A 102 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A(E>5 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 W1 COATING A U 8 1009: METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTIONS UNKNOWN A U OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ M000RING 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING E] 5 GROUND WATER MONITORING F-] 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES NO 1. TIM TED DATE LAS UFD(MOIDAY SUBSTANCE REMAINING _GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED TINDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, l--TRUE AND CORRECT DATE APPLICANTS NAME `�,�y L7 ' 2—��`r LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# ❑ - -a-- IRATION DATE __-- PERMIT NUMBER PERMIT APPROVED BYlOATE PERMIF EXP 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 FOR0¢16B.R6 FORM B (12-911