BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORN'A WATER RESOURCES CONTP I. BOARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM " ' TANK PERMIT APPLICATION INFORMATION �%% - TANK CO ETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _ _ L I� 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 FACILITY/SITE NAME WHERE TANK IS INSTALLED: /` (FZ FARM TANK-YES ET NO C I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY c:: A. OWNERS TANK ID p B. MANUFACTURED BY: M C. YEAR INSTALLED I I D. TANK CAPACITY IN GALLONS: O 0 O 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 ❑ ETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEAD ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT 4 ROIL 1 PRODUCT ❑ 4 GASAHOL 5 FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS [:] 80 EMPTY ❑ 95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL 99 OTHER(DESCRIBE IN ITEM 0,BELOW) D. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF jj HAZARDOUS SUBSTANCE STORED&C.A.S.# (-y�� h e4l— V/ C.A.S.4: III. TANK CONST! TION MARK ONE ITEM ONLY IN BOX A B,C,A D A TYPE OF I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH ORERIOR UNER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 ,PER ❑ 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑3 FIBERGLASS OEI'4 STEEL CLAD W/FIBERGLASS RENFORCED PLASTIC S.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLOFMDE ❑ 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR F7 RUBBER UNE ❑ 2ALKYO LINING ❑ 3EPDXY UNING ❑ 4 ENOLIC UNING LINING ❑ 5 GLASS UNING ❑6 UNLINED 95WN ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO OTHER D.CORROSION ❑ 1 POLYETHLENEWRAP ❑ 2 TAO OR ASPHALT ❑3 WRAP ❑ 4 RBERGlA58 REINFORCE PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ktj 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IFABO GROUND. U IF UNDERGROUND.BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A 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 POLYVINYLCHLORIDE(PVC) U 4 FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP U 3 t00%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 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3VADOSE WELLS P S ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS 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 PENAL TY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID 0 TANK ID N ✓ [1-11 � o / � y 000 CURRENT LOCAL AGENCY FACILITY 10♦/^7/V �(/••� / APPROVED BY NAME PHONE 0 WITH AREA CODE PERMIT NUMBER PERMIT AP TEJ/(! PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT 'URCHARGE AYT. FEE CODE nEIPT 0 BY. FORM B(6-29-EM) THIS FORM MUST BE ACCOMPANR.--,r A FACILITY/SITE APPLICATION, FORM `A',UNLESS k_iRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY _.