BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIP WATER RESOURCES CONTROI BOARD "`••�•'' FORM 'B': UNDERGROUND STORAGE TANK PROaRAM TANKTANK PERMIT APPLICATION INFORMATION TANK. Z COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH 10 MARK ONLY ❑ 1 NEWPERMIT ❑ 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONE ITEM [:] 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSUREy,/ ❑8 TANK REMOVED f ca FACILITY/SITE NAME WHERE TANK IS INSTALLED: U' A' 0z \ y�jcyN F PM TANK-YES F-1NO (a W I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY � ) C3 A. OWNERS TANK IDR B. MANUFACTURED BY: V kl D. TANK CAPACITY IN GALLONS. Q 06 C. YEAR INSTALLED v II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM O. A. 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. L] 1 UNLEADED L]2 LEADED ❑3 SEL 3 CHEMICAL PRODUCT ❑4 OIL PRODUCT L]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&C.A.S.R �� C.A.S.R: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF ❑ UBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM V 2 SINGLE WALLED [—]4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ I STEEL/IRON ❑ 2 STAINLESS BTEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALqWNUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL 9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXYLINING ❑ 4 PH NOCK LINING LINING ❑ 5 GLASS LINING ❑6 UNLINED UNKNOWN ❑ ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑I POLYETHLENE WRAP ❑ 2 TARORASPHALT ❑3 LWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 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 5 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(Uj 95 UNKNOWN A U 99 OTHER A U i 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 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 5 UNKNOWN A O 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 5 5 GROUND WATER MONITORING WELLS (T P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 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 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. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION R AGENCY R FACILITY ID R TANK ID R �l Q U D CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE M WITH AREA CODE d G/G 5� /i✓.� PERMIT NUMBER PERMIT APPROVALOATi PERMIT EXPIRATION DATE CHECKR PERMIT AMOUNT "URCHARGE AMT. FLEE RECEIPTN BY: L4 FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A C RRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY