Laserfiche WebLink
�►' STATE OF CALIFORNIA <br /> /► STATE WATER RESOURCES CONTROL BOARD 3 3 <br /> (v UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY 1 NEW PERMIT a 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION a 7 PERMANENTLY CLO ED ON SITE <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT a 6 TEMPORARY TANK CLOSURE Q 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.t �� B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MWAY/YEAR) D. TANK CAPACITY IN GALLONS: �V <br /> II.TANK CON NTS IFA-1 IS MARKED.COMPLETE ITEM C. <br /> A. 1 MOTOR VEHICLE FUEL a 4 OIL B. C EGULAR 3 DIESEL a 6 AVIATION GAS <br /> UNLEADED <br /> a 2 PETROLEUM F7 80 EMPTY 1 PRODUCT a lbPREMIUM <br /> q 5 GASAHGASAH FUEL 7 METHANOL <br /> UNLEA <br /> JET <br /> a 3 CHEMICAL PRODUCT F7 95 UNKNOWN 2 WASTE 0 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.;r: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C.AND ALLTHAT APPLIES IN BOXDAND E <br /> A. TYPE OF F-] 1 DOUBLE WALL F-] 3 SINGLE WALL WITH EXTERIOR LINER Q 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTEDTANK) 0 99 OTHER <br /> B. TANK 1 BARE STEEL a 2 STAINLESS STEEL a 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL 5 CONCRETE a 6 POLYVINYL CHLORIDE 7 ALUMINUM 8 100% METHANOL COMPATIBLEW/FRP <br /> (PrimaryTank) 9 BRONZE a 10 GALVANIZED STEEL �;�UNKNOWN 99 OTHER <br /> O 1 RUBBER LINED a 2 ALKYD LINING = 3 EPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR O 5 GLASS LINING a 6 UNLINED 5 UNKNOWN 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO <br /> D.CORROSION 1 POLYETHYLENE WRAP a 2 COATING 0�WRAP Q 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION a 5 CATHODIC PROTECTION a 91 NONE 95 UNKNOWN O 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A(D SINGLE 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 1 BARE STEEL 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 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9NILED STEEL A U 10 CATHODIC PROTECTION p 9 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION L1 AUTOMATIC LINE LEAK DETECTOR2 LINE TIGHTNESS TESTING O 3 TERSTITIAL <br /> MONITORING 99 OTHER <br /> V.TANK LEAK DETECTION <br /> 1 VISUAL CHECK a 2 INVENTORY RECONCILIATION 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING F--] 5 GROUND WATER MONITORING <br /> a 6 TANK TESTING a 7 INTERSTITIAL MONITORING 91 NONE a 95 UNKNOWN r-1 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 0 NO 0 <br /> SUBSTANCE REMAINING GALLONS I 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 DATE <br /> (PRINTED&SIGNATURE} <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OFTHE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK# AWK-Z <br /> STATE 04 COUNTY <br /> i I I I I 1 1 A9UZ11 N 3 1ti <br /> PERMIT NUMBER I PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE Lf`� <br /> FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. 7/�' <br />