BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. z ca MARK ONLY ❑ 1 NEWPERMIT ❑3 RENEWALPERMIT n 5 CHANGE OF INFORMATION 7 RMANENTLYCLO NK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE B TANK REMOVED a N FACILITY/SITE NAME WHERE TANK IS INSTALLED: 6 /"1 A,,-V''"e#, S--�r 4 FARM TANK-YES❑ NO (� I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 1fZ A. OWNERS TANK IDR B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS. SOU II. 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 koAODUCT ❑ 4 GASAHOL ❑5 J FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY [:]95 UNKNOWN 2 WASTE ❑7 METHANOL OTHER(DESCRIBE IN REM D,BELOM D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF 4A/Q a r C.A.S.R: HAZARDOUS SUBSTANCE STORED&C.A.S.R YL' YC III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A. TYPE OF ❑ 1PWBUE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM LE WALLED ❑4 SECONDARY CONTAINMENT ❑98 OTHER 1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVAN12m STEEL ❑95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBERUNED ❑2 ALKYD LINING ❑3 EPDXY UNING ❑4 P OUC UNING C. INTERIOR 5 GLASS UNING6 UNLINED 95 UNKNOWN LINING ❑ ❑ ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑i POLYETHLENEWPAP ❑2 TARORASPHALT ❑3 WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVEGROUND, U IF UNDER ROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A Lv3 GRAVITY A U 91 NONE A U 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 5 UNKNOWN A U 99 OTHER A U 1STEEL/IRON A U 2 STAINL.ESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) AA 4 FIBERGLASS PIPE A U 91 NONE � C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U ?STEELCLAD W/FRP IV 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER V V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. qS 1 VISUAL CHECK P 5 2 INVENTORY RECONCILIATION P 8 3 VADOBE WELLS P S 4 ELECTRONIC MONITOR P S S GROUND WATER MONITORING WELLS S 6 PRECISION TESTING 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 TA NK 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION R AGENCY R FACILITY ID R TANK ID R d / W7 CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE C7 IVGIL 7 (� klAlr PERMIT NUMBER PERMIT APPROV DATE PERMIT EXPIRATION DATE Z 7.d �io 1 CHECK R PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT R BY: \,T1.1\VIII FORM B(6-29-Bei THIS FORM MUST BE ACCOMPA D Y A FACILITY/SITE APPLICATION, FORM 'A',UNLE�JURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY _