BILLING - Laserfiche WebLink

Home Browse Search

Now STATE OF CALIFORNI/* WATER RESOURCES CONTROIWARD R FORM `B': UNDERGROUND STORAGE TANK PROGRAM , TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. - '7L MARK ONLY ❑ I NEW PERMIT o 3 RENEWAL PERMIT f TA 'C7 5 CHANGE OF � 7 PERMANENTLY CLOSED TANK ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE TANK REMOVED O A FACILITY/SITE NAME WHERE TANK IS INSTALLED: 10�b n 5 1 N FARM TANK-YES NO A I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY W W A. OWNERS TANK ID# I c D A-1 -zoz I B. MANUFACTURED BY n k A C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS i-I k II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. �1 MOTOR VEHICLE FUEL E] 2 PETROLEUM B. C. ❑ 1 UNLEADED E]2 LEADED 3 DIESEL 3 CHEMICAL PRODUCT 4 OIL �1 PRODUCT ❑ 4 GASAHOL E] 5 JET FUEL E]6 AVIATION GAS 5 HAZARDOUS 60 EMPTY 95 UNKNOWN 2 WASTE 7 METHANOL ©..99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# n k C.A.S.# Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF o I DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER E��5 UNKNOWN SYSTEM o 2 SINGLE WALLED o 4 SECONDARY CONTAINMENT o 99 OTHER B.TANK o I STEEL/IRON o 2 STAINLESS STEEL 3 FIBERGLASS o 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL o 5 CONCRETE 6 POLYVINYLCHLORIDE o 7 ALUMINUM 8 100%METHANOL COMPATIBLE FRP 0 9 BRONZE o 10 GALVANIZED STEEL ©'BS UNKNOWN 99 OTHER 0 1 RUBBER LINED C. INTERIOR o 2 ALKYD LINING o 3 EPDXY LINING o 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING o 6 UNLINED 95 UNKNOWN o IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? o YES o NO o 99 OTHER D. CORROSION o 1 POLYETHLENEWRAP o 2 TAR OR ASPHALT o 3 VINYL WRAP o 4 FIBERGLASS REINFORCED PLASTIC PROTECTION o 5 CATHODIC PROTECTION o 91 NONE 95 UNKNOWN o 99 OTHER IV. PIPING INFORMATION -CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE ASUCTIO A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLEWALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 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 A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD WERE A U 8 100%METHANOL COMPATIBLE ERP A U 9 GALVANIZED STEEL ANKNOW A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S f_VISUAL CHECK) P S 2 INVENTORY RECONCILIATION P S 3 V E WELLS P5 4 ELECTRONIC MONITOR p S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S ] PRESSURE TESTING P S 95 UNKNOWN P S 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 ��• SUBSTANCE REMAINING IN GALLONS INERT MATERIAL' YES NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 16ETE �1 ooa I CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE VY� LLF 30 CC II - 55`� PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIEMV A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A PENT FORMA' HAS BEEN FILED DATA PROCESSING COPY