Laserfiche WebLink
• • '�,60VRCf <br /> STATE OF CALIFORNIA ` <br /> e c5 <br /> STATE WATER RESOURCES CONTROL BOARD sy <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION . FORM B 'e <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 3 f S s-f�r Sfk <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.✓< B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAY/YEAR) /(, D. TANK CAPACITY IN GALLONS: !d O vO <br /> II.TANK CMENTS IFA-11SMARKED,COMPLETE ITEM C. <br /> A. Mi MOTOR VEHICLE FUEL ❑ 4 OIL B. C. IV 3 DIESEL 6 AVIATIONGAS <br /> 4 GASAHOL❑ 2 PETROLEUM ❑ BOEMPTY 1 PROOl1CT � 5 JETFUEL7 METHANOL <br /> 3 CHEMICALPRODUCT 95 UNKNOWN ❑ 2 WASTE 90 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.A <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B.AND C,AND ALL THAT APPLIES IN BOX <br /> A. TYPE OF ❑ 1 UBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER E:] 95 UNKNOWN <br /> SYSTEM NGLE WALL ❑ A SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER <br /> B. TANK 1 BARESTEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP <br /> (PdmaryTmk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER <br /> ❑ 1 RUBBER LINED ❑ 2 &KYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING <br /> C.INTERIOR <br /> ❑ 6 GLASS LINING 8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER <br /> IS UNING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— <br /> D.CORROSION <br /> 1 POLYETHYLENE WRAP �TING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ 6 CATHODIC PROTECTION Z 91 NONE ❑95 UNKNOWN ❑ 99 OTHER <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U WTIOI� IC U 2 PRESSURE IC U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U iCSIRTCE WALL> A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A U BARE A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELWICOATING <br /> A U B 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHOO ROTECTION A U 95 UNKNOWN IC U 99 OTHER <br /> D. LEAK DETECTION ❑ I AUTOMATIC LINE LEAK DETECTOR En 2 LINE TIGHTNESS TESTING ❑ 3 LpNRORI GL ❑ 99 OTHER <br /> V.TANK LEAK DETECTION <br /> ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING <br /> ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES E] NO <br /> SUBSTANCE REMAINING C� GALLONS INERT MATERIAL? <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME <br /> IPPoNTED 3 SIGNATURk� DATE <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> STATE LDACOUNTY# JURISDICTION It FACILITY# TANK# <br /> � �� PITTs3� <br /> PERMIT NUMBER PERMIT APPROVED BV/DATE PERMIT EXPIRATION DATE <br /> FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FORM84W <br />