BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA WATER RESOURCES CONTRF" BOARD FORM 'B': UNDLAGROUND STORAGE TANK PRt;.aRAM TANK - TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. - Z 1 NEW PERMIT 3 RENEWAL PERMIT r1�5 CHANGE OF INFORMATION MARK ONLY F-1 ❑ ULJ ❑ 7 PERMANENTLY CLOSED TANK 10 ONE ITEM ❑2 INTERIM PERMIT ❑d AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE Ej]l TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: S`T. FARM TANK-YES❑ NO ❑ N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY w W A. OWNERS TANK IDN , B. MANUFACTURED BY: �-Ae cn C. YEAR INSTALLED 6. it- D. TANK CAPACITY IN GALLONS: 00(l It. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 'IMOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED n2 LEADED ❑3 DIESEL I- 1 ❑3 CHEMICAL PRODUCT ❑d OIL I_" JCT [-]1 GASAHOL ❑5 JET FUEL ❑S 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 A C.A.S.N C.A.S.N: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A,B,C,AD A TYPE OF ❑I DOUBLE WALLED ❑3 SINGLE WALLED WITH D ERROR LMER UNKNCWN SYSTEM ❑2 SNGLEWAILED ❑1 SECONDARVCONTAINMENT ❑99 OTHER ❑1 STEEL/IRON ❑2 STAIMESSSTEEL ❑3 FIBERGLASS ❑1 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC S.TANK ❑5 CONCRETE ❑9 POLYVINYL CHLORIDE ❑7 AL ❑B I ID%METHANOL COMPATIBLE FRP MATERIAL ❑9 9RWRE ❑ 10 GALVANIZED 5TEEt95 UNKNOWN ❑99 OTHER C.INTERIOR ❑ 1 R BBERUNED ❑2 ALKYD LINING ❑3 EPOKYLINING ❑1 PH NING LIKING ❑5 GLASS LINING ❑B UNLINED 0 95 UNKNOWN ❑ISLNMMATETAALCOMPARBUWITHlOO%METHANOL? ❑YES ❑NO ❑99 OTHER r ON ❑ I Pq.YETFILENEWMP ❑2TAR OA ASPHALT NYL WRAP ❑A FlBEROIASS pEINF0ACGI PLASTIC ION ❑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 97UNKNOWN A U 99 OTHER B. CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 UNED TRENCH A U 91 NONE A U UNKNOWN A U 99 OTHER A U I STELumom A U 2 STAINLESSSTEEL A U 3 POLWINYLCHLORIDEIPVC) A U d FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 9 CONCRETE A U 7 STEEL CLAD W/FRP A U 9 IOD%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEfi�9 1NKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. • S I VISUAL CHECK P 11 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S d ELECTRONIC MONITOR P 9 5 GROUND WATER MONITORING WELLS P B 9 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 9 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE L ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.-WAS FILLED WITH SUBSTANCE REMAINING IN GALLONA 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 A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID N TANK ID S o o / �;- 1�-2 S 0101 / 101 CURRENT LOCAL AGENCY FACILITY ID R APPROVED BY NAME PHONE I W11N AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EKPIRATION DATE q 7CKB PERMITAMOUNT SURCHARGE AMT. FEECODE RECEIPT/ BY: % FORI\MB(B-29-98) THIS FORM MUST BE ACCOMP)�_,ABYAFACRIT MMAlftMTIOK FORM 'A',UNLL, CURRENT FORMA' HASBEENFILED _.l DATA PROCESSING COPY