Laserfiche WebLink
�IE21. <br /> STATE OF CALIFORNIA <br />'M STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY NEW PERMIT 3 RENEWAL PERMIT ❑i 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOPNSLT <br /> ONE ITEM F7 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS--SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D. B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: <br /> ILTANKCONTENTS lFAl IS MARKED,COMPLETE ITEM C. <br /> la REGULAR 3 DIESEL 6 AVIATION GAS <br /> A. F-] 1 MOTOR VEHICLE FUEL 4 OIL C. UNLEADED 4 GASAHOL <br /> F—] 2.1 PETROLEUM F—] 80 EMPTY 1 PRODUCT, ❑ <br /> 1 b PREMIUM ❑ 7 METHANOL <br /> E:] UNLEADED ❑ 5 JET FUEL <br /> 95 UNKNOWN 2 WASTE <br /> CHEMICAL LEADED <br /> DHEIMICAL PRODUCT F 2 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> TE] <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: <br /> 111. 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 <br /> A. TYPE OF <br /> F 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALL F-1 4 SECONDARY CONTAINMENT (VAULTED TANK) E:] 99 OTHER <br /> I BARE STEEL 2 STAINLESS STE <br /> F ELFIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B. TANK <br /> MATERIAL F-1 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE 7 ALUMINUM 8 100% METHANOL COMPATIBLEW/FRP <br /> (Primary Tank) 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> 1 RUBBER LINED <br /> 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING <br /> F <br /> C.INTERIOR <br /> 6 UNLINED <br /> F <br /> LINING F 5 GLASS LINING F 95 UNKNOWN 99 OTHER <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO <br /> F—] 1 POLYETHYLENE WRAP F—] 2 COATING 3 VINYL WRAP <br /> D.CORROSION 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 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 /> rw <br /> A, SYSTEM TYPE A U-1 SUCTION A/U 2 PRESSURE A V 3 GRAVITYA U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL A '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 U4 4 FIBERGLASS PIPE <br /> ti CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U. 7-STEEL W/COATING A U 8 100r/. METHANOL COMPATIBLE W/FRP <br /> -PROTECTION 10 CATHODIC PROTECTION 'A 95 UNKNOWN 99 OTHER <br /> A U 9 GALVANIZED STEEL A U A U <br /> E:] 3 INmoTERSTITTAI <br /> %DETECTION [:] 1 AUTOMATIC LINE LEAK DETECTOR El 2 LINE TIGHTNESS TESTING NrroRING ❑ 99 OTHER <br /> Y.TANK LEAK DETECTION <br /> ❑ I VISUAL CHECK F7 2 INVENTORY RECONCILIATION F—] 3 VADOZE MONITORING F_-r"AUTOMATIC TANK GAUGING 5 GROUND WATER MONITORING <br /> 7 INTERSTITIAL MONITORING 91 NONE UNKNOWN <br /> 6 TANK TESTING 95 99 ,OTHER <br /> V1.TANK CLOSURE INFORMATION <br /> F2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES NO <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL? <br /> ESTIMATED DATE LAST USED(MO/DAY/YR) <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 q. <br /> (PRINTED&SIGNATURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK# <br /> STATE I.Dl 11 1 1 1 161 11 el-31 <br /> PERMITNUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE,,_�� <br /> THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORMS (1 2-91) FOR003413-R6 <br /> "oll l. <br /> _k <br />