BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORP _I WATER RESOURCES CONT : BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION Go COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑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 y FACILITY/SITE NAME WHERE TANK IS INSTALLED: i 0 C FARM TANK-YES❑ NO ❑ 1 •Q I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN–SO SPECIFY A. OWNERS TANK IDR B. MANUFACTURED BY: uN C. YEAR INSTALLED (,�N D. TANK CAPACITY IN GALLONS Q ISI IL TANK CONTENTS IF(AA),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL 2 PETROLEUMfl 1 PRODUCT C ❑4 GASAHO D ❑ 5 JET DUEL ❑6 AVIATION GAS 3 CHEMICAL PRODUCT 4 OIL ❑ 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.R C.A.S.R: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,AD A.TYPE OF ❑I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 95)INKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT 99 OTHER ❑ 1 STEEL/IRON ❑ 2 STAINLESS BTEEL ❑3 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 UMINUM ❑B 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER UNED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑4,911ENOLIC UNING LINING ❑ 5 GLASS LINING ❑6 UNLINED 95 UNKNOWN ❑ ISUNING MATERIAL COMPATIBLE WITH 100KMETHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ INYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑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 U 2 PRESSURE A U 3 GRAVITY A U 91 NONE U 95 NKNOWN A U 99 OTHER S.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 UNEDTRENCH A U 91 NONE A U..A UNKNOWN A U 99 OTHER A U 1 STEELARON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUMA CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED ST U 9 NKNOWN 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 P 8 2 INVENTORY RECONCILIATION P 8 3 NODOSE WELLS d ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P S 7 PRESSURE TESTING P 6 91 NONE P 8 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES ❑NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION R AGENCY RFACILI `Z R TANK ID k ® F—I l O CURB OCAL AGENCY FACT ITY IDR APPROVED BY NAME PHONE f WITH AREA CODE PERMIT NUMBER PERMIT ERMIT E APPROVAL DATE PXPIRATION DATE CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE ^-CEIPTR BY: ;z t FORM B(6-29-66) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SRE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY