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 NFORMATION FOR EACH TANK. - — Z 10 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMR EV5 CHANGE OF INFORMATION ❑7 PERMANENTLYCLO NK ONE ITEM F-12INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED N FACILITY/SITE NAME WHERE TANK IS INSTALLED: 13 Z ` © ISO ST- FARM TANK-YES❑ NO 00 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY N A. OWNERS TANK ID# e. MANUFACTURED BY: w C YEAR INSTALLED U D. TANK CAPACITY IN GALLONS. �(.J 11. TANK96NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A ❑ 3 CHEMICAL PRODUCTL ❑ 4 OIL ROLEUM u PRODUCT C ❑4 GASAHOLD ❑ 5 JET LEADED F]6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY E]95 UNKNOWN L❑I 2 WASTE ❑7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.W 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXA,S,C,SO A. TYPE OF D/bOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEM Lo 2 NGLEWALLED ❑4 SECONDARY CONTAINMENT E]99 OTHER 19 1 STEEUIRON ❑ 2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/RBERGLASS REINFORCED PUS TIC B. TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER UNED ❑2 ALKYD LINING ❑ 3 EPDXY LINING n 4AENOUC LINING LINING ❑ 5 GLASS LINING ❑6 UNLINED 95 UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑ 99 OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHALT NYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION E-]91 NONE 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMTION 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 91 NONE A 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A 1 SINGLE WALLED ,A U 2 DOUBLE WALLED A U 3 UNEDTRENCH A U 91 NONE U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 RSERGLASS PIPE A U 91 NONE C. MATERIAL A U 5ALUMINUM ABCONCRETE A U 75TEEl CLAD WEEP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER V. LEAK DETECTIO SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. S 1 VISUAL CHECK 6 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 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 OFGALLONS 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 3q oo I l 00 3 CURRENT LOCAL AGENCY FACILITY ID k APPROVED BY NAME PHONE N WITH AREA CODE r '-F PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE P=^.EIPT N BY: u FORM B(6-29-fie) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA HAS BEEN FILED .:ATA PROCESSING COPY