BILLING - Laserfiche WebLink

Home Browse Search

Cyo . e STATE OFCALIFORNIA � �~ . STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. It MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANCE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS•- SPECIFY IF UNKNOWN A. OWNER'S TANK I.O.X 1l n0owri B. MANUFACTURED 9Y: u r n C. DATE INSTALLED(MO/DAY/YEAR) W1 W/)6VJyj ti Fox l9ql D. TANK CAPACITY IN GALLONS: 15, 000 111. II.TANK CONTENTS IFA-11SMARKED.COMPLETE ITEMC. 1 MOTOR VEHICLE FUEL 4 OIL B, C 1a REGULAR O 3 DIESEL 6 AVIATION GAS A u ❑ UNLEADED ❑ 4 GASAHOL ❑ ❑ 2 PETROLEUM EMPTY 1 PRODUCT ❑ 1bPREMtUM5 SET FUEL ❑ 7 METHANOL UNLEADED❑ 3 CHEMICAL PRODUCT V96 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.III: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C.AND ALL THAT APPLIES W BOX D A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN SYSTEM I 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK. F-11 BARE STEEL F7 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL CLAD W!FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE 6 POLYVINYL CHLORIDE E ALUMINUM 8 100'i METHANOL COMPATIBLE WIFRP (Primary Tank) 9 BRONZE 10 GALVANIZED STEEL V5 UNKNOWN 99 OTHER F7 1 RUBBER LINED ❑ 2 ALKYD LININGV96 EPDXY LINING 4 PHENOLIC LINING C.INTERIOR 5 GLASS LINING ❑ 6 UNLINED UNKNOWN 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES NO D.CORROSION F-� 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN F 99 OTHER Vfl k%Z61VJ/1 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 99 OTHER at)etl6-dl Y'I B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U S UWNNKNOA 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 WICOATING A U B 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION �(I�,.0 95 UNKNC_ A U 99 OTH D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING 3 INTERSTITIAL g OTHER Un A:j jfWA MONITORING V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING 4AUTOMATIC TANK GAUGING 5 GROUNDWATER MONITORING ❑ 6 TANK TESTING 7 INTERSTITIAL MONITORING ❑ 91 NONE 95 UNKNOWN ❑ 99 CTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MOIDAYIYR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, 1S TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED d SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW ["o me 'pf COUNTY# JURISDICTION# Lei ---`5 TANK# STATE I.D AlAvAI-31 3 LL I I p' PERMIT NUMRFR PERMIT APPROVED BYIDATE 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. FOR00318144