BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA' WATER RESOURCES CONTROL OARD FORM 'B': UNDER-GROUND NK MAT AM OMPLETERON ° TANK TANK PERMIT APPLICATION CA SEPARATE FORM WITH THE FOLLOWIN NFORMATION FOR EACH TANK. 00 MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT HANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED NK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT !D6!TEMPORARY TANK CLOSURE ❑8 TANK REMOVE ' w FACILITY/SITE NAME WHERE TANK IS INSTALLED: 0/ RM TANK-YES❑ NO W I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY !-� A. OWNERS TANK ID# B. MANUFACTURED BY: C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 14 11. TANK ONTENTS IF(AA),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL PETROLEUM B. C. ❑ 1 UNLEADED ❑22 LEADED 3 DIESEL A. 91 MOTOR VEHICLE FUEL CHEMICAL PRODUCT 4 OIL ❑DUCT ❑4 METHANE FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY E]95 UNKNOWN 2 WASTE ❑7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF , / ♦ e HAZARDOUS SUBSTANCE STORED 8 C.A.S.# L C.A.S.W III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,S D A. TYPE OF ❑ UBLE WALLED F-13 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2. UWALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL F-15 CONCRETE ❑6 POLYVINYLCHLORIDE F-] 7 ALUMINUM ❑ B 100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C.INTERIOR F-11 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING F-]4 PHENOLIC LINING ol LINING ❑5 GLASS UNING ❑6 UNUNED NKNOWN E] IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO �THER D. CORROSION I❑ CATHODIC PROTECTION ❑91 [E 95 UNKNOWN ❑99OTHER TAR OR ASPHALT FIBERGLASS REINFORCED PLASTIC PROTECTION5 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 3 GRAVITY A U 91 NONE A 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U / SINGLE WALLED A U 2 DOUBLE WALLED A 3 LINED TRENCH A U 91 NONE Ac U 5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5ALUMINUM A U 6.CONCRETE A U 7STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL43 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. 8 / VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P f 3 VADOSE WELLS P 6 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P f 95 UNKNOWN P B 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE L ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH GALLONS SUBSTANCE REMAINING IN INERT MATERIAL? F]YES E] NO 'I THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# O O 0 7 0101alL CURRENT LOCAL AGENCY FAC TTY IDX APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE y 268 CNECKX PERMIT AMOUNT I SURCHARGE AMT. FEE CODE RECEIPT k BY: ORM B(6-29-BB) THIS FORM MUST BE ACCOMPANIED BY A FACILITYISRE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEENFILED DATA PROCESSING COPY