BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

`b STATE OF CALIFORNI! WATER RESOURCESCONTRO' OARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWINGINFORMATION FOR EACH TANK. (% Z 10 MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED K ONE ITEM ❑ 2 INTERIM PERMIT F—] 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED , N FACILITY/SITE NAME WHERE TANK IS INSTALLED: /j�h'— S(/1-N ARM TANK-YES❑ NO 4 � I I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY 0 A. OWNERS TANK TO# B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM e. C. 1 UNLEADED ❑2 LEADED ❑3 DIESEL F-13 CHEMICAL PRODUCT ❑9 OILflODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS El HAZARDOUS ❑80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN REM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: Ill. TANK CONSTRUCTION MARKONEITEMONLYINBOXA,B,C,&D A.TYPE OF ❑ I BLE WALLED F-1 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALLED 4 SECONDARY CONTA14NT ❑99 OTHER ❑ 1 STEELPRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS F-1 4 STEEL CLAD W/RBERGLASS REINFORCED PLASTIF B. TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE Ij 7/KOMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑ E/BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER UNED ❑ 2 ALKYD UNING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING - C LIN INTRIR ❑5 GLASS LINING ❑6 UNUNED NKNOWN ❑ISUNING MATERIAL COMPATIBLE NTH 100%METHANOL? ❑YES ❑ NO99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP 2 TARORASPHALT "'❑3 WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND,.0 IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U j 1 SUCTION 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 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A Q 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A 8 CONCRETE A U T STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. /nn/ S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS V P S 6 PRECISION TESTING 5 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 8 99 OTHER V VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OFGALLONS 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUrnNTY# JURISDICTION# AGENCY# FACILITY ID# TT/AAN�NK ID# CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE LA ii 3 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FOPM e Iszs-saI THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY