BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION ; COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 "PERMIT ❑ 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED OZ Iii FACILITY/SITE NAME WHERE TANK IS INSTALLED: anleak_ FARM TANK-YES❑ NO z I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY 10 A. OWNERS TANK ID# L)1) L B. MANUFACTURED BY: C. YEAR INSTALLED I C D. TANK CAPACITY IN GALLONSG W II. TANK C9WENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),ISNOT MARKED,COMPLETE ITEM D. (,V A_ 1 MOTOR VEHICLE FUEL F-12 PETROLEUMB. C. 1 UNLEADED ❑2 LEADED ❑ 3 DIESEL F-13 CHEMICAL PRODUCT ❑4 OIL 1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL E] 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.X C.A.S.R; x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,d D A. TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINERUNKNOWN SYSTEM ❑2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEELIIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE [j7 ALU INUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑ 10 GALVANIZED STEEL UNKNOWN ❑99 OTHER ❑ 9 BRONZE C. INTERIOR ❑ 1 RIBBER UNED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑6 UNLINEDUNKNOWN ❑ ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ I POLYETHLENEWRAP ❑2 TAO OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑ 91 NONE NKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A 095 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYLCHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U R 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 6>6 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. y.� P S I VISUAL CHECK S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS II// P 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED,( 0/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH /�V/ /L GALLONS SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO /O THIS FORM HAS BEEh COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED S SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY k JURISDICTION# AGENCY# FACILITY ID k TANK ID N EHGIl = 1 b y U C) c U Z CURRENT LOCAyy,,AO��ENCY FACILITY ID a APPROVED BY N E PHONE a WITH AREA CODE l,orvTl I z \v\I PERMIT NUMBER PERMIT APPROVAL DATE PII EXPIRATION opg V 7. CHECK R PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT• BY: FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIE[TMY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A-CURRENT FORM'A' HAS BEEN FILED W S