Laserfiche WebLink
STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `B': UNDERGROUND STORAGE TANKINFORMATIONGRA <br /> TANK PERMIT APPLICATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> TANK O <br /> 1 NEW PERMIT 3 RENEWAL PERMIT E]5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK <br /> MARK ONLY <br /> ONE ITEM 7 2 INTERIM PERMIT D 4 AMENDE PER 7 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED hofl W <br /> FARM TANK-YES NO IV <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY Q <br /> B. MANUFACTURED BY: <br /> A. OWNERS TANK IDB <br /> C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: OO <br /> II. TANK CONTENTS i , (A.I),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. MQIOR.YFHIGLE EL 2 PETROLEUM B. C. UNLEADED Ej 2 LEADED 3 DIESEL <br /> 3 CHEMICAL PRODUCT F-1 4 OIL PRODUCT 4 GASAHOL 0 5 JET FUEL 6 AVIATION GAS <br /> ❑5 HAZARDOUS [] 90 EMPTY ❑95 UNKNOWN 2 WASTE E17 METHANOL 0 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.B.B: <br /> HAZARDOUS SUBSTANCE STORED A C.A.S.BAid <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,AD <br /> A TYPE OF 1 DOUBLE WALLED <br /> -13 SINGLE WALLED WITH EXTERIOR UNER 95 UNKNOWN <br /> SYSTEM SINGLE WALLED ❑4 SECONDARY CONTAINMENT 99 OTHER <br /> EUIRON 2 STAINLESS STEEL ❑3 FIBERGLASS 4 STEEL CLAD W/RBERGLASS REINFORCED PLASTIC <br /> B.TANX F-� 5 CONCRETE 6 POLYVINYLCHLORIDE 7 ALUMINUM 810096 METHANOL COMPATIBLE FRP <br /> MATERIAL <br /> 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> 1 RUBBER LINED 2 ALKYD LINING 3 EPDXY LINING ❑4 PHENOLIC LINING <br /> C. INTERIOR <br /> LINING ❑SGIASS LINING �8 UNLINED UNKNOWN <br /> IS UNING MATERIAL COMPATIBLE WITH IOD%METHANOL? YES [:] NO 99 OTHER <br /> D. CORROSION ❑ I POLYETHLENE WRAP 2TAR OR ASPHALT 3VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION 91 NONE UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A SYSTEM TYPE A SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> S.CONSTRUCTION A SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 9/ NONE A U 95 UNKNOWN A U 99 OTHER <br /> A STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE <br /> C.MATERIAL A 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> 1 VISUAL CHECK 0S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS <br /> P 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF &WAS TANK FILLED WITH <br /> /4 <br /> „ GALLONS SUBSTANCE REMAINING IN INERT MATERIAL? YES 0� NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION B AGENCY B FACILITY ID B TANK ID# <br /> CURRENT LOCAL AGENCY FACILITYI APPROVED BY NAM PHONE N WITH AREA CODE <br /> � /a <br /> PERMIT NUMBER PERMIT APPROVAL DATE RM1T EXPIRATION DATE <br /> CHECKN PERMIT AMOUNT SURCHARGE AMT. FEE CODE pECE1PTN BY: <br /> FORM B(6-29-66) THIS FORM MUST BE ACCOMPANIEU`UY A FACILITY/SITE APPLICATION, FORM 'A',UNLE59' RENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />