SITE HISTORY - Laserfiche WebLink

Home Browse Search

' 1' � t`OUpGe9 i STATE OFCALSFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B .a o COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. AMARKLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL!PERMIT ❑ 5 CHANGE OF INFORMATION v PERMANENTLY CLOSED ONSITEONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE TANK REMOVED �j 09A OR FACILITY NAME WHERE TANK IS INSTALLED: lte I I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IFUNKNOWN A OWNER'S TANK 1.D.t R. MANUFACTURED BY: C. (TATE INSTALLED(MNOAYNEAR) ` 0. TANK CAPACITY IN GALLONS: i [I.TANK CONTENTS IFA-1ISMARKED.COMPLETE ITEM C. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL g, C. ❑ la REGULARn 3 DIESEL ❑ 8 AVIATION'GAS UNLEADED L^]i 4pHOL 1 PRODUCT Ib PREMIUM 0 ❑ 2 PETROLEUM ❑ BG EMPTY ❑ 7 METHANOL ❑ UNLEADED 5 ,TET FUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED E] 99 OTHER (DESCRIBE IN f1EM-D. BELCV.) 0. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.4' i III. WANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES 0.B.ANO C.ANO ALL THAT APPLIES IN BOK D A TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER 0 1 BARE STEEL ❑ 2 STAINLESS STEEL f73 FIBERGLASS ❑ 4 STEEL CLAO WI FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE E.7 ALUMINUM El8 100Y. METHANOL COMPATIBLE WlFRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 AUSBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR 0 5 CLASS. LIKING ❑ 8 UNLINED y ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 1009E METHANOL 7 YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATINGS ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED.PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER y IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF LINDE RGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER S. CONSTRUCTION A U 1 SINGLE WALL A U 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 U 4 FIBERGLASS PIPE i. CORROSION A U 5 ALUMINUM A U 8 CONCRETE A U 7 STEEL W!COATING A U 8 100% METHANOL COMPATIBLE WrFRP 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 OETECTOR Co 2 LINE TIGHTNESS TESTING ❑ 3 IMHOTNROfi1NG ❑ 99 OTHER V.TANK LEAK DETECTION I ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING 0 5 GROUND WATER MC.NITORING ❑ 8 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER i VI.TANK CLOSURE INFORMATION r F1.ESTIMATED DATE LAS US MO/DAYIYR) 2.ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH �{ SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES ❑ N6 I THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED 6 SIGNATURE) - LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW e#ry COUNTY# JUAISQICTION# FACILITY# TANK# STATE I.D.#5/ q 'C( PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORM B (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. - roRom46..74