BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATEOFCAUFORMA STATE WATER RESOURCES CONTROL BOARD UNDERGROUN STORAGE TANK PERMIT APPLICATION - FORMS ly; . C PLETE A SEPARATE FORM FOR EACH TANK SYSTEM. 7524-44 MARK ONLY ❑ 1 NEW PERMIT IV3 RENEWAL PERMIT C ❑ 7 PERMANENTLY CLOSED RE O ONE REM ❑ 2 INTERIM PERMIT 6 AMENDED PERMIT 8 TEMPORARY TANK CLOSURE O 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.D.0 7524-44-SU-1 B. MANUFACTURED BY: RHEEM C. DATE INSTALLEO(MODAYNEAR) .T D. T-NK CAPACITY IN GALLONS: 000 II.TANK CONTENTS IFA-I IS MARKED,COMPLETE REM C. A, 'L'J 1 MOTOR VEHICLE FUEL ❑ 4 OIL S. G ❑ 18REGULAR 3 DIESEL ❑ 6 AVIATION GAS UNLEAD❑ 2 PETROLEUM ❑ 80 EMPTY 1 PROIXICT J1 10 PREMIUMIII��III 4 �µpL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT % UNKNOWN 2 LEADED 9 OTHER]ESL/ UNLEADED y„� 9L(DESCRIBE IN ITEM D. BELOW) 2 WASTE u D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.•: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLES IN BOX D AND A. TYPE OF _[❑� I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 96 UNKNOWN SYSTEM �(7kAr1 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANKJI BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 0 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PdmvyTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERGR ❑ 5 GLASS LINING ❑ 6 UNLINED % UNKNOWN ❑ 90 OTHER LINIIS LINING MATERIAL COMPATIBLE WITH 100%METHANOL 7 YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ®95 UNKNOWN 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EGUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A-U 1 SUCTION A If 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION Ag 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U % 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 af,14 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 CATHODX:PROTECTON A U % UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING ❑ 3M0 NRORaK0 09 OTHER V.TANK LEAK DETEC,TITIOON� [:] 1 VISUAL CHECKS-_I - INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING 4 AUTOMATIC TANK GAWING ❑ 5 GROUNDWATERMONITORING 8 TANK TESTING L 7 INTERSTITIAL MONITORING ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 YES [:] NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME pgTE 1PmK A wOrMTu LOCAL AGENCY USE QkY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY x JURISDICTION x FACILITY x TANK x STATE I.D. llolql PERMIT NUMBER PERMIT APPROVED 8Y/DATE PERMIT EXPIRATION DATE FORM 8 (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. 6r►/