Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `B': UNDERGROUND STORAGE TANK PROGRAM <br /> TANK PERMIT APPLICATION INFORMATION <br /> TANK L�COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. - <br /> MARK ONLY ❑ i NEWPERMIT ❑ 3 RENEWALPERMIT5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK 1 <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDEDPERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED C7 J <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: ;/ (� y2 FARM TANK-YES❑ NO Cyl <br /> N <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY <br /> // I..► <br /> A OWNERS TANK IDR r� / B. MANUFACTURED BY: Li/(C (,Ti <br /> C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: -Lr <br /> II. TANK C_ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A7),IS NOT MARKED,COMPLETE ITEM D. <br /> A. 1 MOTOR VEHICLE FUEL ❑2 PETROLEUMC. ❑ 1 UNLEADED 2 LEADED ❑ 3 DIESEL <br /> B. I ppODU <br /> ❑3 CHEMICAL PRODUCT ❑4 OIL CT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS <br /> ❑5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.B CAS.W <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D <br /> A.TYPE OF ❑ I DOUBLE WAILED ❑3 SINGLE WALLED WITH EXTERIOR UNER ❑ 95 UNKNOWN <br /> SYSTEM 0SN LE WALLED ❑4 WCaIDAW CONTAINMENT ❑99 OTHER <br /> 1 STEELIIRON ❑2 STAINLESS STEEL F-13 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED RUSTIC <br /> B.TANK ❑ <br /> MATERIAL5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM F-1HAN <br /> B 100%METOL COMPATIBLE FRP <br /> ❑9 BRONZE ❑10 GALWWIZED STEEL ❑95 UNKNOWN ❑99 OTHER <br /> ❑ <br /> C. INTERIOR 1 RUBBER UNED ❑2 LINING F-13 EPDXY LINING ❑4 PHENO IC LINING <br /> LINING ❑5 GLASS LINING 6 UM9NED ❑95 mm" <br /> ❑IS LINING MATERIAL COMPATIBLE NTH 100%METHANOL? ❑YES ❑NO ❑99 OTHER <br /> D. CORROSION ❑I POLYETHlENENRAP ❑2 T ASPHALT ❑3 VIWL WRAP ❑4 FIBERGLASS REINFORCED PLASRC <br /> PROTECTION ❑5 GTHODCPROTECTION 91 NONE ❑95 UNKNOWN ❑99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A 5 UNKNOWN A U 99 OTHER <br /> B. CONSTRUC71ON A U-1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 UNEDTRENCH A U 91 NONE U 95 UNKN A U 99 OTHER <br /> A - STFFI/ A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE <br /> C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 6 10D%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> LP8 1 VISUALCHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS <br /> 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1.ESTIMATED DATE LAST USED(MOLAR) 2. ESTIMATED OUANTITY OFGALLONS 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION B AGENCY B FACILITY ID A TANK ID M <br /> = = = O / 0 F 9 0 0 2 / <br /> CURRENT LOCAL AGENCY FACILITY ID I APPROVED BY NAME PHONE I WITH AREA CODE <br /> PERMITNUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CHECK• PERMITAMOUNT BURCH• -EAMT. FEE COOS BECEIPTr <br /> FORMB(6-29-66) THIS FORM MUST BE ACCOMPANIED BY AF /SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HASSEENFM - <br /> nwre eonrccmrar rnov <br />