BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

N STATE OF CALIFORNIA `e STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B l� COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED O SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4pAMENDED PERMIT ❑ TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: PC:A)S" raUc,KgSi:. (" (-, 19$0 E N1/ y F c roA✓ c I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN II. O A. OWNER'S TANK I.D.# N B. MANUFACTURED BY: O ADGR A.! C. DATE INSTALLED(MO/DAY/YEAR) v <N O W j D. TANK CAPACITY IN GALLONS: ,,Z eo O II.TANK CONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. A ® 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ® la REGULAR ❑ 3 DIESEL ❑ e AVIATIONGAS ❑ 2 PETROLEUM ❑ SO EMPTY 1 PRODUCT ❑ 1bUNLEAID D ❑ 5 JET FUEL ❑ 7 METHANOL ❑ 3 CHEMICAL 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.s III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B,AND C,AND ALL THAT APPLIES IN BOX A. TYPE OF ILy 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 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 ALUMINUM �❑ 8 100% METHANOL COMPATIBLE W/FRP (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 LINING ❑ 99 OTHER /V Q,aJ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 54 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 AID 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U / SINGLE WALL Ao 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 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 04 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ®,2 LINE TIGHTNESS TESTING ❑ 3 INTERSTITIAL 99 OTHER MONRORING tif V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING M 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.ESTIMATED 94AELAST USED(MO/DAY/YR) 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 MWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME t 64 DATE (PRINTED 851GNATUREI ndGM Sel , LC os�• ' LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE F4 NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK#000\STATE I.D.# m U 16-17 117 131 PERMITNUMBER PERMIT APPROVED BYIDATE PER EXPIRATION DATE FORM B (9-90) THIS FORM MU5r BEAG/COMPANIIEEDDt`J/ �BBYY�'�A`-'PEE'R'�M�ITT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. A/tw %o z � \I'd� lo- F6R00I96R1 '`i Saar