BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNV ` WATER RESOURCES CONTR(.BIII)OARD ; FORM B': UNDifl)GROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TA ONE ITEM F--] 2 INTERIM PERMIT E]4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE TANK REMOVED I /I FACILITY/SITE NAME WHERE TANK IS INSTALLED: Llczn' 444 1:k- FARM TANK•YES❑ NO I L1 • I. TANK DESCRIPTION COMPLETE ALL ITEMS•IF UNKNOWN-SO SPECIFY C) A. OWNERS TANK ID# I B. MANUFACTURED BY: GI, C. YEAR INSTALLED bl. D. TANK CAPACITY IN GALLONS: 7 <010 rag II. TANK p6NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF IRA),IS NOT MARKED,COMPLETE ITEM D. W A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED 3 DIESEL F-13 CHEMICAL PRODUCT ❑4 OIL 1 PRODUCT ❑ 4 GASAHOL ❑5 JET FUEL ❑ 6 AVIATION GAS E:] 5 HAZARDOUS ❑ 80 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 STOFkD&C A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOT(A,B,C,6 D A TYPE OF ❑ 1 DOUBLEWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEEL/IRON 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 IW%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑ 2 AL OUNING ❑3 EPDXY LINING ❑4 PHENOLIC LINING C. INTERIOR LINING ❑5 GLASS LINING ❑6 UNLI ❑95 UNKNOWN - ❑ IS LINING MATERIAL COMPATIBLE WITH 100%M ANOL? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHUENEWRAP ❑2 TAR OR ASP T ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE AIFABOVE GROUN UIFUNDERGROUND,BOTHIFAPPLICABLE A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE AU 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER LL B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WAA U 3 LINED TFENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEELRRON A U 2 STAINLESS STEEL 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 U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SE ONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3VADOSE WELLS 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P 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 SUBSTANCE REMAINING IN GALlO14 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 7 0 l 0 3 6 00 LCHECK# A IENCY FACILITY IQN APPROVED BY NAME PHONE k WITH AREA CODE •Jy (rjY PERMITAPPROVAL DATE P RMIT PIRATION DATE PERMIT AMOUNT SURCHARGE ANT. FEE CODE RECEIPTN BY: FORM B(6-29-88) THIS FORM MUST SE ACCOMPANIED Sim PLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY