BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

`W Y� STATEOFCAUFORNA "•�° `i _ STATE WATER RESOURCES CONTROL BOARD i S UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 6 CHANGE OF INFORMATION � 7 PERMANENTLY CLOSED ON SITE ONE REM ❑ 2 INTERIM PERMIT F-14 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 5 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A.OWNERS TANK I,D.a B. MANUFACTURED BY: l C. DATE INSTALLED(NICIDAYA'EAR) V D. TANK CAPACITY IN GALLONS: ILTANKCONTENTS IFA-11S MARKED.COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ a OIL B. C. laUN EARED 3 DIESEL ❑ e AVIATION GAS ❑ 2 PETROLEUM ❑ BO EMPTY I PRODUCT ❑ 1E PREMIUM A GASAHOL ❑ 7 METHANOL UNLEADED 5 JETFUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 9B OTHER (DESCRIBE IN ITEM O.BELOW) D. IF(AI)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.8: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C.AND ALL THAT APPLES IN BOX D ANDS A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINERU -95 UNKNOWN- SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TAW � 99 OTHER B. TANK 1 BARE STEEL F-12 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ A STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PAmmYTwA) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL,-$Q 96 UNKNOWN ❑ N OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ A PHENOLIC LINING C.INTE NIOR ❑ 5 GLASS LINING ❑ 6 UNLINED f01 95 UNKNOWN ❑ 99 OTHER LING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL 7 YES— NO_ D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION, - Bl NON,,,,__{{� a6 E .,, -a�fi 95 UI9fHOWR- O 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR/ p.N�� OVERFILL PREVENTION EOUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION AU 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A®1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH -AA9BOWN A U 99 OTHER C. MATERIAL AND A V 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A 0)K 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 Q4BWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR X2 LINE TIGHTNESS TESTING ❑ MONROANG THERFj - V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORINGtHYA AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING �S TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE .,� - uKNGWM ❑ N OTHER VI.TANK CLOSURE INFORMATION I.ESTIMATED DATE LAST USED(MO/DAY/PR)�! �j(o 2.ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH YES NO SUBSTANCE REMAININGZALLONS INERT MATERIAL? ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, )5 TRUE AND CORRECT APPLICANTS NAME ��. � ^� �� / /� �` ��('/ y DATE �/ ....[) (M3N 0{6K;ryAT - :Fjt, -{�.I'1.1�1 l, /�7 aa )&4 ugal!V[= ) I- � q�: LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY 8 JURISDICTION 8 FACILITY 8 TANK e 0 STATE I.D.# m S .31r] PERMITNUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE /o/1-7/5( 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 FORM B (12.91) FOR90MtM