BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

51 Art OF CALIFORNIA WATER RESOURCES CONTRO' BOARD FORM 'B': UNDL-aROLIND STORAGE TANK PRO TRAM - NA+ TANK TANK PERMIT APPLICATION I FORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWIN NFORMATION FOR EACH TANK •^ MARK ONLY ❑ 1 NEW PERMIT ❑ O RENEWAL PERMIT S CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM 2 INTERIM PERMIT F-14 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑6 TANK REMOVED FACILITY/BITE NAME WHERE TANK IS INSTALLED: 7 Aawv , FARM TANK-YES❑ NO NQ I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-90 SPECIFY A. OWNERS TANK ION D. MANUFACTURED BY: W C. YEAR INSTALLED 0. TANK CAPACITY IN GALLONS �I II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A1),19 NOT MARKED,COMPLETE ITEM D. (J( A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED 0 DIESEL ❑ 7 CHEMICAL PRODUCT ❑ A OIL ❑ I PRODUCT ❑ A 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 A C A.S.N C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A TYPE OF ❑ I DOUBLE WALLED ❑ J SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑A SECONDARYCONTAINMENT ❑ 99 OTHER ❑ I STEEUIRDN ❑ 2 STAIMESSSTEEL ❑ B FIBERGLASS ❑ /STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ MATERIAL 5 coHcaE7E ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ B IBD%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ IB GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ C. INTERIOR I RUBBER UNED ❑2 ALWO LINING ❑ B EPOAYLINING ❑ K PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑ 6 UNLINED ❑%UNKNOWN ❑ IS LINING MATERIAL COMPA11BLE WITH IO(I%METHANOL? YES ❑ ND ❑99 0111[n D. CORROSION ❑ I POLYETHLENEWRAP ❑2 TARORASPHALT ❑B WNYLWRAP ❑A FIBERGLASS REINFORCED PLASTIC 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 I SUCTION A U 2 PRESSURE A U 0 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U J LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U N FIBERGLASS PIPE A U 91 NONE G MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A' U 7 STEEL CLAD W/FRP A U R 100%METHANOL COMPATIBLE FRP A U 9 OALVANIZED 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 9 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S O VADOSE WELLS P N A ELECTRONIC MONITOR P / 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 9 1 PRESSURE TESTING P 1 91 NONE P N 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE UST USED(MO/YR) 2. ESTIMATED OUANTITY OF J. 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 WY KNOWLEDGE.IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N III---A-�IFGENNCCYII9N--1I� FACILITY ID N TANK ID N ---), / 7 CURRENT LOCAL AGENCY FACILITY ID 9 - By NAM[ PRONE/WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE q CHECK F PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N FORM B(S-29-0B) THIS FORM MUST BE ACCOMPANIL, A FACILITY/SDE APPLICATION, FORM 'A',UNLESS A )RRENT FORMA' HAS BEEN FILED V1/ nATA Ponf`Fcd M^ �11-