BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNI/ WATER RESOURCES CONTRO' 'OARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM `'' Ya, TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. ERMANENTLY CLOSED MARK ONLY 1 NEW PERMIT F-13 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑ 7 TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ^ ❑6 TEMPORARY TANK CLOSURE ❑6 TANK REMOVED cl, FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK IDN 63 8. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: D C!J IL TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. 0 A. Cj�,f MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED E2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL gal 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 8 C.A.S.# JA C.A.S.#: .Ill. TANK CONSTRUCTION MARK ONE NEM ONLY IN BOX A,B,C,8 D A. TYPE OF ❑ I UBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLEWALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER P�J<S EEUIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CUD W/RBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑7 ALUMINUM ❑B 10D%MERYNOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER C. INTERIOR F–] 1 RIBBER LINED ❑ 2 ALKYD LINING F-13 EPDXY LINING ❑4 PHENOLIC UNING � LINING ❑5 GLASS LINING rJ"UNLINED ❑95 UNKNOWN ❑ISUNING LIATERIALCOMPATIBLEMTH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CAiHODICPROTECTION91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABO EGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 1 SUCTION A PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A 1 SINGLE WALLED A V 2 DOUBLE WALLED A U 3 LINED TRENCH A U 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 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 95 UNKNOWN A U 99 OTHER A VLEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 1VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 5 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLSP PRECISION TESTI* 8 ] PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 8 99 OTHEI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE ST USED(MO/VR) 2. ESTIMATED DUAN ITY OF 3. WAS TA K FPL1ED WITH SUBSTANC R MG IN IN RIAL? ❑YES [—] NO _ GALLONS I THIS FORM H S BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLE E,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED ASIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# = = 10 1 () I l 1Z I I lq- 6 10 13' CURRENY FACILITY ID# APPROVED B PHONE N WITH AREA CODE T CAL S ZZ E PERMIT NUMBER MWD w E YI O DA E PERMIT EXPIRATION DATE CHECK* PERMIT AMOUNT L.SURCHARGE AMT. FEE CODE RECEIPT# BY: y FORM a 13-7-ee:, THIS FORM MUST BE ACCOMPANIES A FACILITY/SITE APPLICATION, FORM 'A',UNLESS Al.:.IRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY