BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

• `� — pfso . e STATE OF CAUFORMA cam* STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B 4npn COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. � MARK ONLY ❑ I 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 59, 6 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: C,j�`� , I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNERS TANK I.D.8 ?1 1 B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: ILTANKCONTENTS IFA-/ISMARKED.COMPLETE ITEM C. IA REGULAR 3 DIESEL A �1 MOTOR VEHICLE FUEL E] 4 OIL B. C. ❑ UNLEADED ❑ S AVIATION GAS F-] 2 PETROLEUM ❑ 80 EMPTY x1 PRODUCT 10 PREMIUM 4 GASAIWL ❑ 7 METHANOL UNLEADED 5 JET FUEL ❑ 3 CHEMICAL PRODUCT E:] 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 OTHER (DESCRIBE N ITEM D.BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OFSUBSTANCE STORED P mid YG de C.AS:(: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLES IN BOX D AND A. TYPE OF ❑ 1_ DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER �.�UNKNOWN SYSTEM LS 2 SINGLE WALL [j4 SECONDARY CONTAINMENT (VAULTEDTANIQ 99 OTHER B. TANK JE4 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PdmwyTmk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ,II Y JJNKNOWN— ED99 OTHER ❑ 1 RUBBER LINED ❑ 2 AU(YD LINING ❑ 3 EPDXY LINING ❑ 4'PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO_ D.CORROSK)N ❑ I POLYETHYLENE WRAP ❑ 2 COATNG ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC YE PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE �, .,,�_. 95 UNKNOWN L] 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR)fV±1Fy,�1Rlu././ OVERFILL PREVENTION EOUIPMENT INSTALLED(YEAR)WfAj.2U,7j IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U i SUCTION ACUI 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 A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A01 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A(U-i4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 6 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION *Q95-UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑I AUTOMATIC.LINE LEAK DETECTOR W2 LINE TIGHTNESS TESTING ❑ MONRORNG - S9=OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE 95 UNKNOWN ❑ W OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATEDOUANTfTYOF 3.WAS TANK FILLED WITH YES ISYS NO ❑ SUBSTANCEREMAINING GALLONS INERT MATERIAL? /� THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGEWIS TRUE AND CORRECT APPLICANTS NAME DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY 9 JURISDICTION# r-�FrAC�ILITY 9 TANK# STATE I.D.# m l _311 o I�17 PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE 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 FORME (12-91) FORUGH6M