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 TANK PERMIT APPLICATION INFORMATION y <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. - z <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CJ r5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM ❑ 2 INTERIMPERMIT ❑ 4 AMENDEDPERMIT [_]6 4EMPORARY TANK CLOSURE ❑8 TANK REMOVED <br /> N <br /> Ail <br /> ( <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: v S/ N, NJ W L gly FARM TANK-YES V NO ❑ -01b, <br /> fJ <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY (D <br /> A. OWNERS TANK ID N B. MANUFACTURED BY: GjTA.�J <br /> C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS Q Lit) <br /> II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED DIESEL <br /> 3 CHEMICAL PRODUCT 4 OIL 5JA-PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS <br /> 5 HAZARDOUS 0 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.N C.A.S.#: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> I UBLE WALLED F-13 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN <br /> A. TYPE OF 1:1 <br /> SYSTEM &l SINGLE WAUB ❑4 SECONDARY CONTANMENT ❑99 OTHER <br /> 1 STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 MEL CLAD WFIBERGLASS REINFORCED PLASTIC <br /> B.TANK 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM 81DAMETHANOLCOMPATIBLEFRP <br /> MATERIAL <br /> 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER I <br /> ❑ 1 RUBBER UNED ❑2 ALKYDUNING 3 EPDXY UNING ❑4 PHENOLIC UNING <br /> C. INTERIOR <br /> LINING F—] 5 GLASS UNING 194UNLINED [_ 95 UNKNOWN L <br /> F] IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES [_ NO OTHER <br /> D.CORROSION ❑ I POLYETHLENE WRAP 2 TAR OR ASPHALT ❑3 VIW-WRAP ❑4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHODIC PROTECTION [—]91 NONE ❑95 UNKNOWN ❑ 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE IFAS VE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A.SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLEWALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> A U 1 STEELARON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE <br /> C. MATERIAL A 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD WEEP A U 8100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANI ZED 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 /> -- v i VISUAL CHECK P 3 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 5 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS <br /> v 5 6 PRECISION TESTING S ] PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMGALLONS <br /> TED DATE LAST USED IMO/YR) 2. ESTIM ED QUANTITY OF 3. WA TANK FILLED WITH <br /> BS NGE REMAINING IN IN ATERIAL? YES NO <br /> ICI <br /> THI FORM HAS BEEN COMPLETED UNDER PENAL OF PERJURY,AND TO THE BEST OF MY KNOW EDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE � <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID N <br /> s- � I O 151 <br /> CURRENT LOCAL <br /> ,AOENCY FACILITY IDN APP VED BY NAVE <br /> PHONE#WITH AREA CODE <br /> N LIV <br /> d � <br /> PERMIT NUMBER PERMIT APPROVAL E RMIT kXPIRATION DATE <br /> CHECKM PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: <br /> FORM B(6-29-86) THIS FORM MUST BE ACCOMPANIEaBY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A-,dRRENT FORMA' HAS BEEN FILED <br />