BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. (a MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: A Q D W( re m FARM TANK - YES ❑ NO 1- TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY A. OWNERS TANK ID# L( �, }� p15 7 �rU B. MANUFACTURED BY: "• C. YEAR INSTALLED' D. TANK CAPACITY IN GALLONS'.to o 11. TANK CONTENTS IF (A.1), IS MARKED, COMPLETE ITEM C. IF (A.1), IS NOT MARKED, C MPLETE ITEM D. A. EVI MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL EZI"PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS 11 ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER (DESCRIBE IN ITEM O, BELOW) D. IF NOT MOTOR VEHICLE FUEL, ENTER NA OF HAZARDOUS SUBSTANCE STORED & CA.P, C.A.S. #: MI. I. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, ! D A. TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR UNER ❑ 95 UNKNOWN SYSTEM M-irSINGIE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER B. CONSTRUCTION 1 STEEUIRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8100% METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER A U 4 FIBERGLASS PIPE ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING❑ 6 UNLINED A U 8100% METHANOL COMPATIBLE FRP 95 UNKNOWN AU99 ❑ B UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHIENE WRAP TAR OR ASPHALT ❑ 3VINYLWRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE A& 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A �& SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8100% METHANOL COMPATIBLE FRP AU99 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER - SURCHARGE AMT. I FEE CODE ,RECEIPT# V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY, OR S FOR SECONDARY, A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. o1 P S 1 VISUAL CHECK 40: S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 5 5 GROUNDWATER MONITORING WELLS P (�6 PRECISION TESTING P 6 7 PRESSURE TESTING P 6 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED (MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH �NT�YY �� Mo SUBSTANCE REMAINING IN INERT MATERIAL? ❑ YES ❑ NO 1 GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME (PRINTED 8 SIGNATURE) I DATE JURISDICTION # ## CCO�J�U AGENCY # FACILITY ID # TANK IIDD�#� �NT�YY �� Mo �J 1/ /-., V �/ / / / W � O o I l CURRENT LOCAL AGENCYFACILITY ID # APPROVED BY NA PHONE # WITH AREA CODE PERMITN MBER PERMIT APPROVAL DAW PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT - SURCHARGE AMT. I FEE CODE ,RECEIPT# BY: FORM B (3-7-66) THIS FORM MUST BE SITE APPLICATION, FORM -N, UNLESS A DARENT FORMA' HASBEENFILED DATA PROCESSING COPY