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BILLING_PRE 2019
EnvironmentalHealth
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EHD Program Facility Records by Street Name
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ELEVENTH
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2300 - Underground Storage Tank Program
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PR0503795
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BILLING_PRE 2019
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Entry Properties
Last modified
11/19/2024 10:19:22 AM
Creation date
11/4/2018 4:29:31 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2300 - Underground Storage Tank Program
File Section
BILLING
FileName_PostFix
PRE 2019
RECORD_ID
PR0503795
PE
2381
FACILITY_ID
FA0005978
FACILITY_NAME
STAN MORRI FORD
STREET_NUMBER
104
Direction
W
STREET_NAME
ELEVENTH
STREET_TYPE
ST
City
TRACY
Zip
95376
APN
23505307
CURRENT_STATUS
02
SITE_LOCATION
104 W ELEVENTH ST
P_LOCATION
03
P_DISTRICT
005
QC Status
Approved
Scanner
SJGOV\rtan
Supplemental fields
FilePath
\MIGRATIONS\E\ELEVENTH\104\PR0503795\BILLING.PDF
QuestysFileName
BILLING
QuestysRecordDate
12/20/2012 8:00:00 AM
QuestysRecordID
80389
QuestysRecordType
12
QuestysStateID
1
Tags
EHD - Public
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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM B': UNDERGROUND STORAGE TANK PROGRAM " <br /> TANK TANK PERMIT APPLICATION INFORMATION ' <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> MARK ONLY ❑ 1 NEW PERMIT F13 RENEWALPERMR 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDEDPERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVE / <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED L7W !%- 7q,*- ' FARM TANK-YES❑ NO <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY l <br /> A. OWNERS TANK ID `/ v B. MANUFACTURED BY. U/L/ <br /> C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS:Uf _?OV W <br /> H. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. rsa <br /> A. ❑ 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. �Q C. 1 UNLEADED ❑2 LEADED ❑ 3 DIESEL W <br /> 9 ❑3 CHEMICAL PRODUCT ❑1 ' OIL ❑ 1�PRODUCT ❑<GASAHOL ❑5 JET FUEL ❑ 6 AVIATION GAS <br /> ❑5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ©-- 1 A$TE ❑7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM 0 BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# /'3- /v / C.A.S.#r 13 <br /> .III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A. TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTE If 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER <br /> ❑ I STEEL/IRON ❑ 2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B.TAN /7/ ❑ 5 CONCRETE ❑ 6 POLriINYL CHLORIDE ❑ 7 AL INUM ❑ B 100%METHANOL COMPATIBLE FRP <br /> MATE L <br /> ❑9 BRONZE ❑10 GALVANIZED STEEL LpM UNKNOWN ❑ 99 OTHER — <br /> ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY UNING ❑4 PH LICUNING <br /> C. INTERIOR ❑ 5 GLASS LINING ❑6 UNLINED 5 UNKNOWN <br /> /� ❑ IS UNING MATERIAL COMPATIBLE MTH t00R MEMAN ❑YES NO ❑99 OTHER <br /> D. CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VW WRAP ❑4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE Ek4uNKNOWN ❑ 99 OTHER <br /> IV. PIPING INFO _ NATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A SYSTEM TYP A U 1 SUCTION A U 2 PRESSURE A 3 GRAVITY A U 99 OTHER <br /> R.CONSTRUCTI A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A'6 3 UNEO TRENCH A(PZ) <br /> UNKNOWN A U 99 OTHER <br /> / A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(P ) A U 4 FIBERGLASS PIPE <br /> C. MATERIAL /Y A U 5 ALUMINUM A JL 4 CONCRETE A U 7 STEELCLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZEDSTEEL A/N H5 UNKNOWN A U 99 OTHER <br /> V. LE ETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P 1 VISUAL CHECK P 9 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS <br /> tn.lp P S 6 PRECISION TESTING P S ] PRESSURE TESTING 9-41 1 NONE P S 95 UNKNOWN P S 99 OTHER <br /> �VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> TIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3, WAS TANK FILLED WITH <br /> N SUBSTANCE REMAINING IN GALLONSINERT MATERIAL? ❑YES E] NO <br /> THIS FORM HAS BI COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> VENT <br /> JURISDICTION# AGENCY# FACILITY ID# L7 TANK ID# <br /> oUao aba:GENCY FACII ID# VED BY NAMEPHONE 0 WITH AREA CODE <br /> R r/C9' 8gVe PERMIT APPROVAL DATE PERMIT TION DA <br /> CHECK# PERMIT AMOUNT _ SURC HIUMEAMT. FEECODE RECEIPT BY: <br /> oRM B 13a 7 THIS FORM MUST BE ACCOMPANIPC$Y A FACILITY/SITE APPLICATION, FORM 'A',UNLESS ATARRENT FORMA HAS BEEN FILED <br />
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