BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNI1WATER RESOURCES CONTRO(--�ARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM ` TANK TANK PERMIT APPLICATION INFORMATION g COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. -—- S'.. MARK ONLY X1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS TA ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT za 6 T PO TANK LOU ❑8 T K REMOV FACILITY/SITE NAME WHERE TANK IS INSTALLED: G FARM TANK-YES❑ NO ()'I I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY y A. OWNERS TANK ID A 2 B. MANUFACTURED BY: 5 �N n C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: .7-0 , 000 II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. fVr1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM1B. C. ❑ 1 UNLEADED E] 2 LEADED 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL kl PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑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&C.A.S.N C.A.S.W III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF 1 DOUBLE WALLED ❑3 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.TANK WMATERIALF-15 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑610D%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑W OTHER ❑ 1 RUBBER LINED ❑2 ALKYD LINING X3 EPDXY LINING ❑4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING ❑6 UNLINED ❑ 95 UNKNOWN ❑ ISUNING MATERIAL COMPATIBLE WITH ion METHANOL? ❑YES 2<140 ❑ 99 OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑ 2 TARORASPHALT ❑3 VINYL WRAP L4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U / 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 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 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8100%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. o^ I P 8 1 VISUAL CHECK 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS W 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P 8 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 Al/�/L GALLONS SUBSTANCE REMAINING IN INERT MATERIAL? [:]YES ❑NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO�11 THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED S SIGNATURE) VA L DATE I/AnIdEWc, t�lr>FrzAe�sEss,�.rc /i /� �8 LOCAL AGENCY USE ONLY COUNTY R JURISDICTION B AGENCY S FACILITY ID N TANK ID R CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE K WITH AREA CODE v co 1 o 1 �s PERMITNUMBER PERMIT APPROVAL DATEPERMIT EXPIRATION DATE JL z7 CHECK M PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT4 BY: FORM B(6-2s-ea) THIS FORM MUST BE ACCOMPANIE A FACILITY/SITE APPLICATION, FORM'A',UNLESS A RENT FORM W HAS BEEN FILED DATA PROCESSING COPY