Laserfiche WebLink
1y�W l:.i Y <br /> r " P.,c�pURC eS Co 'p.l <br /> i' STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD a , <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B 6 ' ° ` <br /> � { COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> C MARK ONLY F7 1 NEW PERMIT 0 3 RENEWAL PERMIT F--] 5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED # <br /> I ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE B TANK REMOVED I {� <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.# SII ]�J)) B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: OW <br /> r� <br /> ILTANKCONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. k <br /> A. F7 1 MOTOR VEHICLE FUEL 4 OIL B. C. 1a REGUL R 3 DIESEL 6 AVIATION GAS <br /> PETROLEUM O 80 EMPTY 'a 1 PRODUCT 1b PREMIUM D 4 GASAHOL 7:METHANOL <br /> R. UNLEADED 5 JETFUEL <br /> C. 3 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE ft <br /> 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) y ; <br /> F D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED r C.A.S.#: <br /> Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX D AND E ; <br /> 1 DOUBLE WALL �', 3 SINGLE WALL WITH:EXTERIOR LINER 95 UNKNOWN <br /> A. TYPE OF "y <br /> 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER <br /> SYSTEM K4 SINGLE WALL <br /> ` 1 BARE STEEL 2 STAINLESS STEEL 0 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED LI <br /> B. :�TANK \ <br /> MATERIAL 0 5 CONCRETE a 6 POLYVINYL CHLORIDE F7 7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP <br /> (PrimaryTank) F 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 0 99 OTHER <br /> 451 <br /> 1 RUBBER LINED 2 ALKYD LINING 3 EPDXY LINING O 4 PHENOLIC LINING <br /> CJNTNRIIGR 5 GLASS LINING 6 UNLINED El 95 UNKNOWN E] 99 OTHER" <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO <br /> A.CORROSION D 1 POLYETHYLENE WRAP 2 COATING 3 VINYL WRAP 4 FIBERGLASS':REINFORCED PLASTIC <br /> PROTECTION F 5 CATHODIC PROTECTION E:�] 91 NONE - 5 UNKNOWN 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) _ <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A 3 GRAVITY A U 99 OTHER <br /> g. ro <br /> B. CONSTRUCTION U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE <br /> :CORROSION AY 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 6 100% METHANOL COMPATIBLE W/FRP � <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER <br /> �> Q. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR Z LINE TIGHTNESS TESTING 3 INTERSTITIAL 99 OTHER <br /> MONITORING : <br /> V.TANK LEAK DETECTION <br /> kD VISUAL CHECK 0 2 INVENTORY RECONCILIATION a 3 VAD02E MONITORING a 4 AUTOMATIC TANK GAUGING 5 GROUND WATER MONITORING <br /> TANK TESTING 7 INTERSTITIAL MONITORING E] 91 NONE 95 UNKNOWN 99 OTHER-r>4#d< tj <br /> „ <br /> VI.TANK CLOSURE INFORMATION <br />' is ESTIMATED�/p/�TWST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY-OF 3.WAS TANK FILLED WITH YES O NO <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL? <br />+;. THIS FORM HAS BEEN COMPLETED LINT R PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANT'S NAME DATE <br /> y (PRINTED&SIGNATURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> C <br /> s COUNTY# JURISDICTION# FACILITY# TANK# <br /> STATE I.D.# ILjy I-T�---I__I <br /> -� — 3s <br /> 111141 JIEI�H <br /> 1I <br /> PERMITNUMBER PERMIT Y!D PERMIT EXPIRATION DATE <br /> FORM B'17-till) THIS FORM MUST BE ACCOMPANIED BY AftNNT APPLfGATLC}N•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> + FOR00346-RS <br />