BILLING - Laserfiche WebLink

Home Browse Search

• • a STATE OF CALIFORNIASTATE WATER RESOURCES CONTROL BOARDNUNDERGROUND 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 ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE [VB TANK REMOVED D DBA OR FACILITY NAME WHERE TANK IS INSTALLED: O I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.a B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAY/YEAR) D. TANK CAPACITY IN GALLONS: D® II.TANK CONTENTS IFA-IISMARKED.COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL E] 4 OIL B. C. 1:118UNLEADED 3 DIESEL ❑ 6 AVIATIONGAS ❑ 2 PETROLEUM ❑ 90 EMPTY Ik 1 PRODUCT ❑ 1b PREMIUM 4 GASAHOL ❑ 7 METHANOL UNLEADED 5 JETFUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE V2 LEADED ❑ ❑ 98 OTHER (DESCRIBE IN ITEM D. BELOW) 0. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.B.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,ANDC.AND ALL THAT APPLIES IN BOX A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER D795 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 UMINUM E:] 9 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 5 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ PDXY LINING ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑ 8 UNLINED 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ INYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN 99 OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 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 TRENCHA U 9 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 STEELWICOATINQ A U B 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U /0 CATHODIC PROTECTION A U UNKNO A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR Q 2 LINE TIGHTNESS TESTING31NTERS TIAL ❑ MONITORING ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 OMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE 5 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE S USED M / Y R 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH 22 ��I SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF My KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME (PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE I.D.# COUNTY# JURISDICTION# LITY# TANK# PERMIT NUMBER PERMIT APPROVED BVD/D TATE P IT EXPIRATION DATE FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED, I FORo134&R4 W 4-1u-c � 0 0 7