BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIP WATER RESOURCES CONTRO' -OARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM L� TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. " 7 10 MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT N �NANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT F-14 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED 5 NO (� FACILITY/SITE NAME WHERE TANK IS INSTALLED: 6000r— E rn-O FARM TANK-YES ElO 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY Cd A. OWNERS TAN S B. MANUFACTURED BY: Lti C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 11, TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),I$NOT MARKED,COMPLETE ITEM D. I A. ❑ ❑ 2 1 MOTOR VEHICLE FUEL �PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑ 3 DIESEL F-13 CHEMICAL PRODUCT I ;1 4 OIL ❑ 1 PRODUCT ❑ 4 GASAHOL ❑5 JET FUEL E]6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN WASTE ❑7 METHANOL J�d OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED S C.A.S.R k/Q Sfe 01' / CA.S.#: 05 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,a D A TYPE OF ❑ 1 DOIIBLEWALLFD ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEMSINGLE WALLED ❑4 SECDNDARYCONTAINMENT ❑ 99 OTHER STEE/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑6 100%METRANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER UNED ❑2 U(YD UNING ❑ 3 EPDXY UNING F-14 PHENOLIC UNING C. INTERIOR LINING ❑5 GLASS LINING 6 DNUNED ❑95 UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METRANOL? ❑YES ❑NO ❑ 99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP TAR OR ASPHALT ❑3 VINYLWRAP ❑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 Sfip2 PRESSURE 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 95 UNKNOWN A U 99 OTHER A U 1 STEELARON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U1 6SCONCRETE A U 7 STEELCLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A�_ 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 S 1 VISUALCHECK 08 2 INVENTORY RECONCIUATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 6 5 GROUND WATER MONITORING WELLS /N Prs)6 PRECISION TESTING P 8 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED QUANTITY OFGILLLONB 3. WASTANKFILLED WITH SUBSTANCE REMAINING IN 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY 8 JURISDICTION S AGENCY R FACILITY ID* TANK ID* © d1 l 5 <S 000 -5 CURRENT LOC4&AGENCY FACILITY ID* APPROVED BY NAMI.ayj PHONE M WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DA'tE PERMIT EXPIRATION DATE CHECK* PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT* BY: V Y FORMB(6-29-88) THIS FORM MUST BEACCOMPANI AFACILITY/SITE APPLICATION, FORM 'A',UNLESS A RENT FORMA' HAS BEEN FILED