BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA.- WATER RESOURCESCONTROL.eARD FORM B': UNDERGROUND STORAGE TANK PROGRAM #98632A (a TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING FORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ®3 RENEWALPERMR 5 CHANGE OF INFORMATION [:] 7 PERMANENTLY CLO,7K ONE ITEM ❑2 INTERIM PERMIT F-14 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: Grantl9I1C CIICVTOn FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID N WC6377C B. MANUFACTURED BY: XERX C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 10,000 gallons II. TANK CONTENTS IF(A7),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. A. ® l MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. © 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ d OIL ❑X 1 PRODUCT ❑A GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 CAS.8 CAB 0: 8006619 III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A,8,C,S D A.TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ®2 SINGLE WALLED ❑A SECONDARY CONTAINMENT ❑99 OTHER ❑ I STEEUIRON ❑2 STAINLESS STEEL ❑X 3 FIBERGLASS ❑A STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC 8.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑B IOD%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER F-] I RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING E-] /PHENOLIC UNING JUN 2 7 1 90 C.`IN LINING F--] ❑5 GLASS LINING ®6 UNUNED ❑95 UNKNOWN E] ISLINING MATERIAL COMPATIBLE NTH ITM%METHANOLI YES ❑ NO ❑99 OTHER ENIVIRONMFNTA HEALTH D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYLWRAP ❑A FIBERGLASS REINFORCED PLASTIC ' ICES PROTECTION ❑ 5 CATHODIC PROTECTION ®91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER 8.CONSTRUCTION AW 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U %UNKNOWN A U 99 OTHER A U 1STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) AW < FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U "OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY.OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 8 1VISUAL CHECK S 2 INVENTORY RECONCILIATION P S 3VADOSE WELLS P B O ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS qJ 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P 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 FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL' ❑YES ❑NO THIS FORM HAS BEEN COMPLETED UNDER PENH F PERJUR , N T E OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE V. --. 30H soFJ1 6- IS - 50 LOCAL AGENCY USE ONLY COUNTY S JURISDICTION B AGENCY! ACIUTY ID R TANK ID B Jol IFAd g o0 2 CURRENT LOCAL AGENCY FACILI ID! APPIIOYEO BY HAVE PHONE A WITH ARG CODE 5-_7 PEIIMIT NUMBER PERYR APMOVAL DATE PERMIT EKPIMTION DATE CHlCRI PERMIT AMOUNT SURCHARGE AMT. FEE COD! RECEIPT6 BY: v� V FORM B(6 29-89) THIS FORM MR E ACCOIMAW "FACBftYME NMBEIVTMIM, FORM'X.UMM A O' F A' HAS SEEN FLED n COPY \ v 1 DATA PR�SSING COPY O LOCNRL AGENCY COOF �'4� ��