BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNit WATER RESOURCES CONTROL ')ARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT R/' CHANGE OF INFORMATION ❑ 7 PERMANENTLY 0 ANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED / FACILITY/SITE NAME WHERE TANK IS INSTALLED: O E C �✓ D3FMM TANK-YES❑ NO Z I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 10 A. OWNERS TANK ID A / I B. MANUFACTURED BY:ff Vceff I r C. YEAR INSTALLED O D. TANK CAPACITY IN GALLONS: fQO O W II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED, OMPLETE ITEM D. A_ 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL PRODUCT ❑4 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&CAS.N C.A.S.W All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,S.C.B D A.TYPE OF 0,LffOUBLE WALLED ❑3 SINGLE WALLED WITH Ex FORCE UNER ❑95 UNKNOWN SYSTEM oz 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1.SSF EUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/RBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYL CHLORIDE n k46MINUM ❑B 100%MET14ANOL COMPATIBLE FRP MATERIAL Lr�J/ ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBERLINFD ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING LJ 4 PHENOLICUNING LINING ❑5 GLASS UNING ❑6 UNUNED "KNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METMANOL? ❑YES 0N �THER D. CORROSION ❑ I POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT � F--]VIWLWRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION E] 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 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A S 6 CONCRETE A U ] STEELCLADW/FRP A U 8100%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. / S 1 VISUAL CHECK P 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS �1�/J S 6 PRECISION TESTING P S ] PflESSURE TESTING P 8 91 NONE P S 95 UNKNOWN P S 99 OTHER V VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MONK) 2. ESTIMATED QUANTITY OF 3,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 MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID M TANK ID N 1 71 A l = = I a I v I I-FoTefflL91 o I v / CU ENT LO AGENCY CIIRY IDN �1,1 /ry I�21 APPROVED BY NAME PHONE M WITH AREA CODE PERMIT NUM ER / PERMITAPPROVAL DATEPERMIT EXPIRATION DATE �p CHECK M PERMIT AMOUNT ,SURCHARGE AMT. FEE CODE .BECEIPf• BV: FORM B(3-7-m) THIS FORM MUST BE ACCOMPANItu BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESSA RRENT FORMA' HAS BEEN FILED ESSING COPY