BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNF WATER RESOURCES CONTR BOARD FORM 'B': UNDnGROUND STORAGE TANK PRO-GRAM `- K TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _ - z 10 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OFINFORMATION 7 PERMANENTLY C OSE TANK ONE ITEM F--] 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT [:] 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED / C.J FACILITY/SITE NAME WHERE TANK IS INSTALLED:&Z 0 S, FARM TANK-YES❑ NO 57 N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY N A. OWNERS TANK ID# B. MANUFACTURED BY: G YEAR INSTALLED O. TANK CAPACITY IN GALLONS: / 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. . A. Ef, MOT OR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED ❑3 DIESEL I- 3 CHEMICAL PRODUCT ❑ 4 OILET�lPRODIJCT ❑4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ',��%❑' 5 HAZARDOUS ❑ BO 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.# �/( / A C.A.S.#: WA III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXA,B,C,&D A.TYPE OF ❑�1 DOUBLE WALLED F-13 SINGLE WALLED WITH EXIERCR UNER ❑95 UNKNOWN I�' SYSTEM LJ `SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER SIEEUIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑810D%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER ❑1 RUBBERUNED ❑-!-6w DEWING F—] 3 EPDXY LINING ❑4 PHENOLIC LINING C. INTERIOR LINING F--] 5 GLASS UNING 6 UNLINED ❑95 KNOWN / v ❑ ISUNING MATERIAL COMPATIBLE WITH 100%MEIHANOL? ❑YES ❑NO990THEi D PROTECSION I TION ON ❑5 CATHODIC PROTECTION ❑91TAR OR NONE ASPHALT ❑ 95 UNKNOWN [—] 9FOTHER SS REINFORCED PLASTIC IV. PIPING INFORMA N CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A 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 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE 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 A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U CONCRETE A U 7 STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 95 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 S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS a6P S S PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATEDD TE LAST USED(MO/YR) 2. ESTIMATED QUANTilY OF 3.WAS TANK ILLED WITH SUBSTANCE M IN IN INE M L7 [:]YES ❑ NO GALLONS THIS FO M HAS BEEN COMPLETED UNDER PENALTY OF PERAJRY,AND TO THE BEST OF MY KNOWLED E,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 10 j I I d G lo CURRENT LOCAL AGENCY FACILITY ID N APPROV B BY N E PHONE#WITH AREA CODE C L F �- s PERMIT NUMBER PERMIT APPROVAL DATE 'PERMIT EXPIRATION ISATE PECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: 6(e-29-ee) THIS FORM MUST BE ACCOMPANIEL __A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A. (RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY --