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BILLING_PRE 2019
EnvironmentalHealth
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2300 - Underground Storage Tank Program
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PR0503436
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BILLING_PRE 2019
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Entry Properties
Last modified
12/20/2019 1:52:58 PM
Creation date
11/2/2018 6:59:32 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2300 - Underground Storage Tank Program
File Section
BILLING
FileName_PostFix
PRE 2019
RECORD_ID
PR0503436
PE
2381
FACILITY_ID
FA0002327
FACILITY_NAME
STOCKTON GOLF & COUNTRY CLUB
STREET_NUMBER
3800
Direction
W
STREET_NAME
COUNTRY CLUB
STREET_TYPE
BLVD
City
STOCKTON
Zip
95204
APN
10902006
CURRENT_STATUS
02
SITE_LOCATION
3800 W COUNTRY CLUB BLVD
P_LOCATION
99
P_DISTRICT
003
QC Status
Approved
Scanner
KBlackwell
Supplemental fields
FilePath
\MIGRATIONS\C\COUNTRY CLUB\3800\PR0503436\BILLING.PDF
QuestysFileName
BILLING
QuestysRecordDate
11/7/2012 8:00:00 AM
QuestysRecordID
113679
QuestysRecordType
12
QuestysStateID
1
Tags
EHD - Public
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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM B': UNDERGROUND STORAGE TANK PROGRAM <br /> � d <br /> TANK TANK PERMIT APPLICATION INFORMATION o ,y. <br /> �COOMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> MARK ONLY U1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLE <br /> K <br /> ONE ITEM ❑ 2INTERIM PERMIT ❑ 4 AMENDEDPERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: � & FARM TANK-YES❑ <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECT Ili <br /> A. OWNERS TANK ID 4tiJ`' I B. MANUFACTURED BY: lw... <br /> C. YEAR INSTALLED w K D. TANK CAPACITY IN GALLONS: 14000 <br /> II. TANK ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. I MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB C. Ll1 UNLEADED Ea'2 LEADED E]3 DIESEL <br /> ❑3 CHEMICAL PRODUCT F-14 OIL � PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS <br /> ❑5 HAZARDOUS ❑ 80 EMPN ❑95 UNKNOWN ❑ 2 WASTE ❑7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF A�. <br /> HAZARDOUS SUBSTANCE STORED 8 C.A.S.# * C.A.S.#: <br /> .III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,6 D <br /> A TYPE OF ❑ I DqUBLE WALLED F-] 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN <br /> SYSTEM NGLE WALLED ❑4 SECOIDARVCONTAINMEM ❑99 OTHER <br /> 21�, STEELARON ❑2 STAINLESSSTEEL ❑3 FIBERGLASS ❑ 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP <br /> MATERIAL <br /> ❑9 BRONZE ❑ 10 GALVANIZED$IEEE ❑95 UNKNOWN ❑99 OTHER <br /> � <br /> F-11 RUBBER LINED ❑2 ALKYDUNING F-] 3 EPDXY LINING ❑4 PHENOLIC LINING <br /> C.INTERIOR <br /> LINING ❑ 5 GLASS LINING ❑ I- <br /> fi UNLINED I0"'UNKNOWN <br /> ❑IS LINING MATERIAL COMPATIBLE WITH 10D%METHANOL? ❑YES ❑NO ❑ 99 OTHER <br /> D. CORROSION ❑ 1 POLYEIHLENEWRAP ❑2TAR OR ASPHALT ❑3 VINYLWRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ff24UNKNOWN ❑ 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A 4Q95 UNKNOWN A U 99 OTHER <br /> A U 1 STEEUIRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE <br /> C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P8 1 VISUAL CHECK OP S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> 1 P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3, WAS TANK FILLED WITH <br /> N I1^ GALLONS SUBSTANCE REMAINING IN INERT MATERIAL? E]YES E] NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> D O M S � 1G DO l 9 <br /> CURRENT LOCAL ADENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> s ob <br /> PERMIT NUMBER PERMIT APPROVAL-OkM PERMIT EXPIRATION DATE <br /> CHECKR PERMIT AMOUNT SURCHARGEAMT. FEE CODE ECEIPT# BY: <br /> FORM B(3-7-fi8) THIS FORM MUST BE ACCOMPANIEMY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A RENT FORMA' HAS BEEN FILED <br />
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