BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD 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 ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE a TANK REMOVED / DBA OR FACILITY NAME WHERE TANK IS INSTALLED: !;>jo� ' 5 e I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN / S. MANUFACTURED BY: A. OWNER'S TANK I.D.% C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: D ILTANKCONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. aREGU AR 773 DIESEL ❑ 6 AVIATIONGAS L(A.1) OR VEHICLE FUEL 4 OIL S. C. ❑ UNLEADED 4 GASAHOL A. ❑ 7 METHANOL ROLEUM 80 EMPTY ❑ 1 PRODUCT ❑ 1bPREMIUM UN EADED ❑ 5 JET FUEL MICAL PRODUCT ❑ 95 UNKNOWN2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) MARKED, ENTER NAME OF SUBSTANCE STORED S.#: III, TANK CONSTRUCTION MARK ONE ITEM ONLY IN SOXESA,B.AND C.AND ALLTHAT APPLIES IN BOX D AND ENK1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN OF 98 OTHER M �,y2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK)�1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD WI FIBERGLASS REINFORCED PLASTICK ice' ❑ 8 POLWINVL CHLORIDE ❑ 7 ALUMINUM ❑ 6 100% METHANOL COMPATIBLE W/FRPRIAL ❑ 5 CONCRETE Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING IOR ❑ 5 GLASS LINING IR 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER G IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? VESNO_❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC OSION 95 UNKNOWN 99 OTHER CTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(NEAR) 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 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 89 OTHER C. MATERIAL AND A 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 7 STEEL 95/UNKNOWN A U 99TOM TM METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U O CATHODIC PROTECTION 3A D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ MONBORING 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 1.ESTIM DDA E LAST E (MO/DAV/VR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ N(TPf _ SUBSTANCE REMAINING GALLONS INERT MATERIAL? /L�Nd THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AICD TO THE BEST OF MV KNOWLEDGE, IS TRUE AND CORRECT DATE (PRINTED P YS NAME (PRINTEDINTER A d SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW C�OUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# 4 PERMIT NUMBER PERMIT APPROVED 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 FDR49k&R6 FORM B (1291)