BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA WATER RESOURCES CONTROL ' ARD FORM V: UNDERGROUND STORAGE TANK PROGkAM ' TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWIN INFORMATION FOR EACH TANK. - G MARK ONLY F-] 1 NEWPERMIT [-]3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK 14:1 ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑6 TANK REMOVED O FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO ❑ N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY CTI W A. OWNERS TANK ID# !- U. MANUFACTURED BY: will C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS. 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 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑4 OIL ❑ 1 PRODUCT E]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 8 C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,S D A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEUIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEELCLADW/FIBERGLSS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑ B 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ C. INTERIOR 1 RUSSERUNED ❑2 ALKYD LINING F-13 EPDXY LINING F-14 PHENOLIC UNING LINING ❑ 5 GLASS LINING ❑6 UNLINED ❑95 UNKNOWN ❑IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TARORASPHALT ❑3VINYL WRAP ❑4 FIBERGLASS REINFORCED RASTIC 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 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 FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 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. P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION 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.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN fNLLLONB INERT MATERIAL? ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# I I I / I d I 9 1 1 g CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE Y WITH AREA CODE 3 17 Ap PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEECODE RECEIPT# BY: FORM B(6-29-BB) THIS FORM MUST BE ACCOMPANIED FACILFTY/SRE APPLICATION, FORM 'A!,UNLESS A CURRENT FORMA HAS BEEN FILED DATA PROCESSING COPY