BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORN► ` WATER RESOURCES CONTR' BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. j MARK ONLY ❑ 1 NEWPERMIT [:] 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED K ONE ITEM F-12 INTERIM PERMIT F-] 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE 8 TANK REMOVED t FACILITY/SITE NAME WHERE TANK IS INSTALLED: 6M04LOCA-tlt�& FARM TANK-YES❑ NO 0 Z I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SOSPECIFY ti 10 A. OWNERSTANKIDR 021 B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: TObD co 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. f A A. i MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. [ell, UNLEADED ❑ 2 LEADED ❑ 3 DIESEL , ❑3 CHEMICAL PRODUCT ❑ 4 OIL 1 PROOUCT ❑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) 1, D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME N OF ,. HAZARDOUS SUBSTANCE STORED&C.A.S. /u C.A.S.M All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D UBLE WALLED ❑ 3 SINGLE WALLED WITH DUERIOR UNE E]95 UNKNOWN A.TYPE OF ❑ 1 SYSTEM 2 S LE WALLED —] /SECONDARY CONTAINMENT ❑99 OTHER 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 180%METHANOL COMPATIBLE FHP MATERIAL ❑ 9 BRONZE ❑10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOUC LINING C.INTERIOR IN NG R ❑5 GLASS LINING V 6 UNLINED ❑95 UNKNOWN ❑ISUNING MATERIAL COMPA11BLEWITH 100%METHANOL? ❑YES ❑NO ❑ 99 OTHER D TAR OR ASPHALT R REINFORCED PLASTIC PROTEPROTECTIONE—] E—]5 CATHODIC PROTECTION 91 NONE ❑%UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE & SYSTEM TYPE A(Uy 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER S. CONSTRUCTION ci 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A 1 STEELARON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/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 DETECTIONSYSTEM MUST BE CIRCLED. 1 P 5 1 VISUAL CHECK 0 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS 1111 P 5 b PRECISION TESTING P 8 7 PRESSURETESTING P S 91 NONEP 6 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED QUANTITY OF 3,WAS TANK FILLED WITH GALLONS H N SUBSTANCE REMAINING IN INEFITMATERIAL7 ❑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 I LOCAL AGENCY USE ONLY COUNTY# JURISDICTION k AGENCY N FACILITY ID# TANK ID# ffE D Lo L I Z 1 101010 CURRENT LOCAL AGENCY FACILITY ID N 3 APPR VED BY NAME PHONE N WITH AREA CODE 8� d1K PERMIT NUMBER PERMIT APPROVAL DAfE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BV: FORM B(3-7-BB) THIS FORM MUST BE ACCOMPANIED FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED