BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

,w: STATE OF CALIFORNIA WATER RESOURCES CONTROL E�RD �4 FORM 113". TANK STORAGE TANK PROGRAM TANK PERMIT APPLICATION INFORMATION _. I o TANK ❑7 PERMANENTLY CLO SED COMPLETE A SEPARATE FORM WITH THE FOLLOWIN C INFORMATION FOR EACH TAN MARK ONLY ❑1 NEW PERMIT ❑3 RENEWAL PERMIT ❑6 TEMPORARY TANK CLOSURE ❑6 TANK REMOVED w ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT OD 'I ONE ITEM � FARM TANK-YES NO ❑ FACILITY/SITE NAME WHERE TANK IS INSTALLED: (% FY 1. 'TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—50 S B MANUFACTURED BY: A. OWNERS TANK ID If D. TANK CAPACIN IN GALLONS: C.YEAR INSTALLED ❑3 DIESEL C. ❑ 1 UNLEADED 2 LEADED II. TANK CONTENTS IF(p t),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM • ❑6 AVIATION GAS B. ❑4 GASAHOL ❑5 JET FUEL A l MOTOR VEHICLE FUEL 0 2 PETROLEUM ❑1 PRODUCT E]3 CHEMICAL PRODUCT E]4 OIL 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) F-15 HAZARDOUS ❑BO EMPTY ❑95 UNKNOWN ❑'WASTE ❑ C.A.S.B: CLE FUEL ENTER NAME D, IF NOT TOR HAZARD OUS SUBSTIANCE STORED&C.A.S.BOF III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,!D ❑ UNKNOWN A TYPE OF El DOUBLE WALLED ❑3 SINGLE WALLED WIT N EXTERIOR LINER 95 SYSTEM ❑ 2 SINGLE WALLED4 SECONDARY CONTAINMENT 99 OTHER RCED PLASTIC I STEEVIRON 2 STAINLESS STEEL 3FIBERGLASS 4STEEL CLAD WIFIBERGLASS REINFO B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑B 199%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBERUNED ❑2 ALKYD LINING ❑3 EPDXY LINING �4PLINING 95 UNKNOWN C. INTERIOR 5 GLASS LINING 6 UNUNED LINING ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? YES ❑NO ❑99 OTHER D. CORROSION ❑1 POLYETHLENE WRAP ❑2TAR OR ASPHALT 3VIWLWRAP 4 FIBERGLASS REINFORCED PLASTIC 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 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U i STEELARON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8 100%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 DETECTION SYSTEM MUST BE CIRCLED. P 8 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 3 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 98 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 PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED S SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY B JURISDICTION B AGENCY B FACILITY ID B TANK ID B Q� 7 CURRENT LOCAL AGENCY FACILITY ID "PRO ED BY ME ZZX3,0 PHONE k WITH AREA CODE LPERMITBER L/ (� PERMIT APPROVAL DA PERMITE%PIRAT ON DATE PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPTN ` BY: V FORM B(s-2s-ee) THIS FORM MUST BE ACCOMPANIED BY AFACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED — DATA PROCESSING COPY