BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

g{ STATE OF CALIFORNI1 WATER RESOURCES CONTRC 'OARD FORM 'B': UNDEffGROUND STORAGE TANK PROGRAM w TANK TANK PERMIT APPLICATION INFORMATION �'�' COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 7 MARK ONLY 01"NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS K - ONE ITEM ❑ 2 INTERIM PERMIT F-14 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED AL FACILITY/SITE NAME WHERE TANK IS INSTALLED: I FARM TANK-YES❑ NO (,JI I. TANK DESCRIPTION COMPLETE ALL ITEMS—IF UNKNOWNSOSP W A. OWNERS TANK IDR B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS to DUO II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A_ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C ❑ 1 UNLEADED ❑2 LEADED 3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL 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.K C.A.S.R: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A TYPE OF ❑ I DOUBLEWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM Y?r2BNGLEWALIED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER llrJ ' STEEL/IRON ❑2 STAINLESS STEEL r73 FIBERGLASS ❑4 STEEL CLAD W/RBERGLASS REINFORCED PLASTIC B.TANK MATERIAL ❑ 5 CONCRETE E]6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑8 I00%METHANOL COMPATIBLE ARP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 98UNKNOWN 99 OTHER C.INTERIOR F-1I RUBBER LINED ❑ 2 ALKYD UNING ❑ 3 EPDXY LINING E]4 PHENOLIC LINING LINING ❑5 GL45SUNING E6 UNLINED ❑95 UNKNOW�N� �� ❑ IS LINING MATERIAL COMPATIBLE WITH 100%MEIHANOL? ❑YES E] NO �99 OTHER.16e7C_6= ♦ D. CORROSION ❑ 1 POLYETHLENE WRAP 2TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATI N CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 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 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 Ar sl,6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A V95 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. sP 1 VISUALCHECK S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 6 PRECISION TESTING P S 7 PRESSURE TESTING P 8 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1,ESTIMA ED DATE LAST USED(MO/YR) 2. ESTIMAT D QUANTITY OF 3, S TANK FILLED WITH N SU T EMAINING IN MATERIAL? ❑YES ❑ NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY PERJURY,AND TO THE BEST OF MY KNO LEDGE,IS TRUE AND CORRECT, APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY 4 JURISDICTION P AGENCY k FACILITY ID B TANK ID R I o L) I / � I n I o I o I 3 CURRENT LOCA.AGENCY FACILITY ID N APPROVED BY N ME PHONE N WITH AREA CODE T z I-" LtIf Z�-ty PERMIT NUMBER "TAPV D PERMIT EPIRATION DATE CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: FORM B(6-29-BR) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS OMRRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY