BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

-'..STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `BI: UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING!,NFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 19 - FARM TANK-YES❑ NO z 1. TANK DESCRIPTION COMPLETE ALL ITEM -IF S UNKNOW N-SO SPECIFY i O A. OWNERS TANK ID# # 07� B. MANUFACTURED BY: C. YEAR INSTALLED tfD. TANK CAPACITY IN GALLONS: u► II. TANK CONTENTS IF(aT),18 MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. (p A. ❑ MOTOR VEHICLE FUEL 2 PETROLEUM B. PRODUCT C ❑4 GASAHOLD ❑5 JET FUEL ❑ 6 AVIED 3 ATION GAS 3 CHEMICAL PRODUCT 4 OIL ❑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 STORED 8 C.A.S.# A-1114- C.A.S.#: All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A.TYPE OF F-11 DOUBLE WALLED F-13 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEUIRON ❑ 2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. MATERIAL F-15 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑ 0100%METHANOL COM�PATIB�LEFFU ❑ 9 BRONZE ❑ 10 GALVANIZEDSTEEL ❑95 UNKNOWN3 OTHER ❑ 1 RUBBER LINED ❑2-5w L LINING ❑3 EPDXY'LINING ❑4 PHENOLIC LINING C. INTERIOR LINING ❑5 GIASSUNING UNLINED ❑95 UNKNOWN ❑GUNING MATERIAL COMPATIBLE WRH 100% ETHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLFNE WRAP karTAR OR ASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLI CABLE A SYSTEM TYPE U SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH AC095 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 A6 CONCRETE A U ] STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL 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. �- P 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS �j P 5 6 PRECISION TESTING P S 7 PRESSURETESTING 8 1 NONE P S 95 UNKNOWN P 8 99 OTHER INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE L ESTIMATED DATE LAST USE IMO/VRI 2. ESTIMATED QUANTITY 9F 3.WAS TANK FILLED WITH { N/ SUBSTANCE REMAININGIN INERT MATERIAL? YES ❑ NO 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) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# W = G S o b lo CURRENT LOCAL AGENCY FACT ITY # APPROVED BY IUM�� OMEN WITH AREA CODE PERMIT NUMBERPERMIT APPROVAL DATE rERMIT PIORAATTIIOONO CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(3-]-88) THIS FORM MUST BE ACCOMPANY t"Y A FACILITY/SITE APPLICATION, FORM `A',UNLESS RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY