BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION NFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWI INFORMATION FOR EACH TANK. _ Z MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMI7 EY5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED`7ANK 10 ONE ITEM ❑2INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED T FACILITY/SITE NAME WHERE TANK IS INSTALLED: o2- - W ;�,/J FARM TANK-YES❑ NO N 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# CD D 2- B. MANUFACTURED BY: N C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: S' 1000 II. TANK CONTENTS IF(A7),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEIIII 9( r A. 91 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED [g2LEADED ❑3 DIESEL 3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT E]4 GASOHOL ❑5 JET FUEL ❑ 6 AVIATION GAS ❑ ❑5 HAZARDOUS 80 EMPTY E] 95 UNKNOWN 2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN REM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A. TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEMI-/x2 SINGLEWAU.ED ❑4 SECONDARY CONTAINMENT ❑99 OTHER oe -tSTEEL/IRDN ❑ 2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑B 1DD%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER ❑ C. INTERIOR I RUBBERUNED DLINING F-13 EPDXYLINING ❑ 4 PHENDUCLINING LINING ❑ 5 GLASS LINING UNLINED ❑ 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE Wn METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ I POLYETHLENEWRAP 2 TARORASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED KwI PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑ 99 OTHER IV. PI PINGINFORMATI N CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A IH, SUCTION A U 2 PRESSURE \,A U 3 GRAVITY A U 91 NONE A U 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 95 UNKNOWN A U 98 OTHER A U 1 STEEL/IRON 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 CONCRETE A U 7 STEELCLADW/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U UNKNOWN A U 99 OTHER V. LEAK DETECTION STEM CIRCLE R FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. 1 VISUA PLCHECKK P 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS S PRECISION TESTING P 8 7 PRESSURE TESTING P 8 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 E]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 B SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY IDS TANK ID B REFEI 11910101 -7 CURRENACAI,AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE GSZ� 6 PERMITNUMBER PERMIT APPROVAL DATE PERMIT M TOM ATE CHECK M PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT* BY: FORM B(6-29-BB) THIS FORM MUST BE ACCOMA FACILITY/SITE APPLICATION, FORM 'A',UNLESS A RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY _ _ -