BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNP WATER RESOURCESCONTR( BOARD FORM W: UNDEFAiGROUND STORAGE TANK PROOMRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. --_ z 10 MARK ONLY 1 NEWPERMIT ❑ 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 / FACILITY/SITE NAME WHERE TANK IS INSTALLED FARM TANK-YES❑ NO W N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID# -1/ B. MANUFACTURED BY: C. YEARINSTALLED Zi D. TANK CAPACITY IN GALLONS: 0 QQ 11. 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 PETROLEUMC. -1UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL B. 1 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& � A C.A.S.# C.A.S.#: A) A III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,A D A. TYPE OF ❑ I BLE WALLED F-13 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 BINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER 15TEEL/IRON ❑25TNNLESS STEEL ❑ 3FIBERGLASS ❑ 4STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 810M METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ C. INTERIOR I RUBBER UNED ❑ 2 A INING ❑ 3 EPDXYUNING ❑ 4 PHENOUCLINING LINING ❑ 5 GLASS LINING UNUNEO ❑ 95 U�NKNOWN ❑ ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑-9�OTHER f D. CORROSION ❑ I POLYETHLENE WRAP Fa 2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION F] 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMA ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE FAR PE A - 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER TION A U 1 SINGLEWALLED A U 2 DOUBLEWALLED 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 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE A U S ALUMINUM A 6 CONCRETE A U ] STEEL CLAD W/FRP A U B 100%ME COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 5 UNKNOWN A U 99 OTHER �. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 8 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 6 PRECIS 10N TESTING P S 7 PRESSURETESTING P 8 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.EST;MATEp DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK ILLED WITH SUBSTA40F REMAINING IN IT M IAL? [-]YES ❑ NO GALLONS NER A 4-11 THIS FORM HAS BEEN COMPLETED UNDER PENALTY7W PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE . LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CURRENT LOCAL AGENCY FACILITY ID# APPR VF�D BY NAME ( PHONE#WITH AREA CODE LL '761 PERMIT NUMBER PERMIT APPA ALO PERMIT EXPIRATION DATE l t'� 5 CHECKk PERMIT AMOUNT SURCHARGEAMT. FEE CODE RECEIPT# BY: FORM B(6-29-68) THIS FORM MUST BE ACCOMPAN rgd A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A MARENT FORMA' HAS BEEN FILED DATA PROCESSING COPY