BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIi WATER RESOURCESCONTROARD FORM B': UNDE ROUND STORAGE TANK PRO RAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLO DT NK ONE ITEM F-1 ONEPERMIT ❑ 4 AMENDEDPERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED I FACILITY/SITE NAME WHERE TANK IS INSTALLED: 114000 FARM TANK-YES❑ NO I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY Ll A. OWNERS TANK ID# 2 B. MANUFACTURED BY: ..r C. YEAR INSTALLED '7 3 D. TANK CAPACITY IN GALLONS: W II. TANKCONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. gl MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL F-13 CHEMICAL PRODUCT ❑4 OIL 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL El AVIATION GAS co ❑ 5 HAZARDOUS ❑80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER'(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAMEOF HAZARDOUS SUBSTANCE STORED 8 C.A.S.# /u/4 C.A.S.#: N All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A.TYPE OF ❑ 1-DOUBLE WALLED ❑ 3 SINGLE WALLEDWRHEKIERIOR LINER ❑95 UNKNOWN _ r SYSTEM 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER I 1 STEEUIRON ❑2 STAINLESS STEEL ❑ 3FIBERGLASS ❑4STEEL CLAD W/FIBERGLASS REINFORCED PLAly C B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE,- MATERIAL LUMINUM ❑8100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑10 GALVANIZED STEEL gM UNKNOWN ❑99 OTHER ❑ 1 RUBBER UNED E]2 D LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING C. INTERIOR ❑5 GLASS LINING Dal UNLINED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLEW1TH 100%METHANOL? ❑YES pNO 99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAA OR ASPHALT ❑ 3 VINYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION AU 2 PRESSURE A U 3 GRAVITY A U 99 OTHER - B. CONSTRUCTION A 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A 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 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 11 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. I I P 5 1 VISUAL CHECK P 8 2 INVENTORY RECOKCILIATION P 8 3 VADOSEWELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS p& 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONEP 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 OF 3. WAS TANK,PILLED WITH A SUBSTANCE REM I GALLONS INERT TRI Lk ❑YES ❑ NO I la THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 3m 1 b D ct' I 3 I I Iv o 0 CURRENT LOCAL AGENCY FACILITY ID# APPR VE BY N PHONE#WITH AREA CODE I 3 A' k- PERMIT NUMBER PERIMF APPROVAL DATE PERMIT EXPIRATION DATE 1 [77-# 7 PERMIT AMOUNT SURCHARGEA T.� FEE CODE RECEIPT# BY: W FORM B(3-7-89) THIS FORM MUST BE ACCOMPAAMY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS RRENT FORMA' HAS BEEN FILED ^1-6 "nrrCGlrtlr COPY