Laserfiche WebLink
f s , µ � . r i • <br />CgOURC[:S <br />STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARD 3 <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br />• CSL Ii°1+N' <br />COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br />MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANE CLOSE SIT <br />ONE ITEM F -1F-1❑ 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑ 8 TANK MOVED <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. if <br />UN r &/n ��J <br />B. MANUFACTURED BY: "a )(AI&LO <br />C. DATE INSTALLED (MO/DAYNEAR)I <br />,� <br />D. TANK CAPACITY IN GALLONS: '000 <br />il. TANK CONTENTS IF A-1 IS MARKED, COMPLETE ITEM C. <br />A. ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL <br />B. <br />C. ❑ 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS <br />❑ 2 PETROLEUM ❑ 80 EMPTY <br />1 PRODUCT <br />❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL <br />❑ 1c MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 <br />❑ 3 CHEMICAL PRODUCT F�,9 UNKNOWN <br />❑ 2 WASTE <br />❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOM <br />D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. #: <br />NIA IV. PIPING INFORMATION <br />III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A, B. AND C, AND ALL THAT APPLIES IN BOX D AND E <br />A. TYPE OF <br />11 DOUBLE WALL <br />❑ 3 SINGLE WALL WITH EXTERIOR LINER <br />❑ 5 INTERNAL BLADDER SYSTEM F]95 UNKNOWN <br />SYSTEM <br />�❑ <br />LTJ 2 SINGLE WALL <br />❑ 4 SINGLE WALL IN A VAULT <br />❑ 99 OTHER <br />B. TANK <br />1 BARE STEEL <br />❑ 2 STAINLESS STEEL <br />❑ 3 FIBERGLASS <br />❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC <br />MATERIAL <br />❑ 5 CONCRETE <br />❑ 6 POLYVINYL CHLORIDE <br />❑ 7 ALUMINUM <br />❑ 8 100% METHANOL COMPATIBLEW/FRP <br />(Primary Tank) <br />❑ 9 BRONZE <br />❑ 10 GALVANIZED STEEL <br />❑ 95 UNKNOWN <br />❑ 99 OTHER <br />C. INTERIOR <br />❑ 1 RUBBER LINED <br />❑ 2 ALKYD LINING <br />❑ 3 EPDXY LINING <br />❑ 4 PHENOLIC LINING <br />LINING OR <br />F-]5 GLASS LINING <br />F__]6 UNLINED <br />95 UNKNOWN <br />❑ 99 OTHER <br />COATING <br />IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? <br />YES— NO— <br />D. EXTERIOR <br />❑ 1 POLYETHYLENE WRAP <br />❑ 2 COATING <br />❑ 3 VINYL WRAP <br />❑ 4 FIBERGLASS REINFORCED PLASTIC <br />CORROSION <br />PROTECTION <br />1:15 CATHODIC PROTECTION <br />F21191 NONE <br />❑ 95 UNKNOWN <br />❑ 99 OTHER <br />E. SPILL AND OVERFILL etc. SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) <br />+ DROP TUBE YES NO STRIKER PLATE YES NO DISPENSER CONTAINMENT YES NO <br />CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND, BOTH IF APPLICABLE <br />A. SYSTEM TYPE <br />A U <br />1 SUCTION <br />A U <br />2 PRESSURE A U <br />3 GRAVITY <br />A U <br />4 FLEXIBLE PIPING A U 99 OTHER <br />B. CONSTRUCTION <br />A U <br />1 SINGLE WALL <br />A U <br />2 DOUBLE WALL A U <br />3 LINED TRENCH <br />A U <br />95 UNKNOWN A U 99 OTHER <br />C. MATERIAL AND <br />A U <br />1 BARE STEEL <br />A U <br />2 STAINLESS STEEL A U <br />3 POLYVINYL CHLORIDE (PVC)A U 4 FIBERGLASS PIPE <br />CORROSION <br />A U <br />5 ALUMINUM <br />A U <br />6 CONCRETE A U <br />7 STEEL W/COATING <br />A U 8 100% METHANOL COMPATIBLE W/FRP <br />PROTECTION <br />A U <br />9 GALVANIZED STEEL <br />A U <br />10 CATHODIC PROTECTION <br />A U 95 UNKNOWN <br />AU 99 OTHER <br />D. LEAK DETECTION <br />❑ <br />1 MECHANICAL UNE LEAK ❑ <br />2 LINE TIGHTNESS ❑ 3 CONTINUOUS INTERSTITIAL ❑ 4 ELECTRONIC LINE <br />❑ <br />5 AUTOMATIC PUMP [:] 99 OTHER <br />DETECTOR <br />TESTING <br />MONITORING <br />LEAK DETECTOR <br />SHUTDOWN <br />t4jrk- V.TANK LEAK DETECTION <br />ANNUAL <br />El 1 VISUAL CHECK ❑ 2 R CONCILATIONMANUAL INVENTORY F–]3 MONITORING ❑ VADOZE4 GAUGNGAUTOMATIC TANK ❑ 5 MONITORINGGROUND WATER ❑ 6 TESTINGTANK <br />❑ 7 CONTINUSMON TOR U INTERSTITIAL ❑ 8 SIR ❑ 9 TANEK GAUGANGAL ❑ 10 MONTHLY TANK © 95 UNKNOWN E] 99 OTHER <br />VI. TANK CLOSURE INFORMATION (PERMANENT CLOSURE IN-PLACE) <br />1. ESTIMATED DATE LAST USED (MO/DAY/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES NO <br />NNS SUBSTANCE REMAINING c�T� GALLONS INERT MATERIAL? ❑ <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />TANK OWNER'S NAME 1 DATE <br />(PRINTED & SIGNATURE) Cly LJ / (7 /. r� J i /S -z c/ <br />LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br />COUNTY # JURISDICTION # FACILITY # TANK #— Mj (� <br />STATE LD:# I I I I a D <br />PERMIT NUMBER ERMIT APPROVED BY/DATE I PERMIT EXPIRATION DATE <br />THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION - FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM <br />SHOULD BE ACCOMPANIED BY A PLOT PLAN. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br />FORM B (6-95) <br />11 <br />