BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNI1' WATER RESOURCES CONTROF 'OARD FORM 'B': UNDEMROUND STORAGE TANK PRO XMAM " ' 4'"• TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. :a MARK ONLY ❑ 1 NEW PERMIT F1 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 /S FACILITY/SITE NAME WHERE TANK IS INSTALLED: 5. 3 C e l, FARM TANK-YES❑ NO Z I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY I1� A. OWNERS TANK ID# td-/ eL-- B. MANUFACTURED BY: C. YEAR INSTALLED -' D. TANK CAPACITY IN GALLONS: 7 .5'0 o GL> II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,C MPLETE ITEM❑D. 00 A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B C. 1 UNLEADED 2 LEADED ❑ 3 DIESEL N ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL ZiPRODUCT ❑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 S C.A.S.# Ajq C.A.S.W XIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM F2 SNGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3FIBERGLASS ❑4STEEL CLADW/FIBERGLASS REINFORCED PLASTIC B.TANK F-1 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ B 108%METHANOL COMPATIBLEFRP MATERIAL 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER ❑ I RUBBER UNED ❑2 ALKYD LINING F-13 EPDXY LINING F-14 PHENOLIC LINING C. INTERIOR IN NG R ❑ 5 GLASS LINING F6 NLINED [-]95 UNKNOWN -� / ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES [:] NO THEfl 4-6"v `' D.CORROSION ❑ 1 POLYETHLENE WRAP TAR OR ASPHALT ❑ 3 VINYLWRAP ❑4 FIBEFIBLASS REINFORCED PLASTIC PROTECTION E]5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A ip 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLEWALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH 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 C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLAD W/FRP A U B 100%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 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS 1 H P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN !&9 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED OUANTIIY OF 3, WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? [-]YES ❑ NO j THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED B SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 1 D6 C 8 0o OG' I o5 CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAj'p PHONE#WITH AREA CODE 1 7 ff TT//CC PERMIT NUMBER PERMIT APPROVAL DATE I PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: •L' FORM B(3-7-SS) THIS FORM MUST BE ACCOMPANIft-BY A FACILITY/SITE APPLICATION, FORM 'A',uNLEssklKnENT FORM'W MAS BEEN FILED J DATA PROCESSING COPY