BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNI_ WATER RESOURCES CONTRI 30ARD i FORM 'B' 'UNDERGROUND STORAGE TANK PROGRAM TANK - TANK PERMIT APPLICATION INFORMATION ; ��`COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK z I ' MARK ONLY r7I NEW PERMIT. r70 RENEWAL PERMIT a CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED T 10 ONE ITEM i,.k c',❑ 2 INTERIM PERMIT - ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED W FACILITY/SITE NAME WHERE TANK IS INSTALLED: G//L FARM TANK•YES[I NO (�} O L- TANK DESCRIPTION COMPLETE ALL ITEMS•IFUNKNOWN-60SPECIFY ED A OWNERS TANK ID Y D. MANUFACTURED BY: CD C.YEAR INSTALLED / D. TANK CAPACITY IN GALLONS: If. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM A ❑ I MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED 1 LEADED ❑ S DIESEL ❑ G CHEMICAL PRODUCT ❑ 4 OIL ❑ IPRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL E] 6 AVIATION GAS r75 HAZARDOUS ❑ 80 EMPTY 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM 0,BELOW) D- IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 6 CAS.Y C.A.S.Y: III. TANK CONSTRUCTION MARK ONEITEM ONLY IN BOXA,B,C.&D A.TYPE OF ' ❑ 1 DOUBLE WALLED ❑ 7 SINGLE WAILED WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER I STEEVWON 2STNNLESSSTEFL 3FIBEHGAS6 ❑ 4STEEL CUDW/FISERGUM REINFORCED PLASTIC B.TANK IMATERIAL 5wNcRETE 6POLYVINYLOILORDE 7ALUMINUM 6100461610 NOLCOMPARBUIRP :,f `.. ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER UNEO ❑ 2 ALKY.O LINING ❑ 7 EPDXY LINING ❑ 4 P 04OLC LINING LINING . ❑ 5.GLASS LAM ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ IS UNI MATERIAL COMPATIBLE WITH 100$METHANOL? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ I.WETR.ENEwRAP ❑ 2 TARWASPHALT ❑ 0 VWYLWRAP ❑ 4 RSERGLISSREINFORCEDPLASTIC PROTECTION ❑ 5 CATHODIC PROTECT" ❑ 91 NONE ❑ 95 UNKNOWN 99 OTHER IV, PIPING INFORMATION CIRCLE A IFA13OVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 0 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A u I SINGLE WALLED A U 2 DOUBLE WALLED A U 0 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESS STEEL A U 7 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 6 IOU%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 t 1 VISUAL CHECK P t 2 INVENTORY RECONCILIATION P t 0 VADOSE WELLS P t 4 ELECTRONIC MONITOR P t 5 GROUND WATER MONITORING WELLS P t 6 PRECISION TESTING P 6 7 PRESSURE TESTING P 1 91 NONE P Y 95 UNKNOWN P B 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED CMO/YR) 2. ESTIMATED QUANTITY OF 0.WAS TANK FILLED WITH OALLONt SUBSTANCE REMAINING IN INERT MATERIAL? YES [2 NO ' THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPUCANTS NAME LPRINTED a SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY t '.JURISDICTION Y AGENCY Y FACILITY ID Y TANK ID Y CURRENT LOCAL AGENCY FACILITY IO Y APPROVED BY NAYS PHONE I WITH AREA CODE GT/oa L5/ 6 PEAMITI4UMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK PERMITAMOUNT SUNG NARQE AML 7FEE clout _ ECEIPTI BY; 9 �'.. FORMD(6.29-56) THIS FORM MUST BE ACCOMPANIED BY A FACIUTY/SITE APPLICATION. FORM 'A' I)NL5SSAr11RRFMT Cnn9.v uAc ocmnl�„