BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIN WATER RESOURCES CONTR(�IOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE 2r8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: km' FARM TANK-YES❑ NO Z IO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID# Z B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. D A. Vi MOTOR VEHICLE FUEL PETROLEUM �B. C. 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT 4 OIL Lam ' PRODUCT ❑ 4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑ 99 OTHER(DESCRIBE IN REM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF AA HAZARDOUS SUBSTANCE STORED&C.A.S.# CAS.#: .III. TANK CONSTRUCTION MARK ONE I EM ONLY IN BOX A,B,C,•D A.TYPE OF ❑ DOUBLEWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95UNKNOWN SYSTEM SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEL/RON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 coN,.RErE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑1 RUBBER UNED ❑2 ALKYD LINING ❑3 EPDXY UNING ❑ 4 PHENOLIC UNING C. INTERIOR LINING ❑5 GLASS LINING �6 UNLINED ❑95 UNKNOWN ❑ ISUMNG MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER O ION ❑ NONE ASPHALT 3 VINYL❑ 9FIBERGLASS REINFORCED PLASTIC PROTECT5 CATHODICPROTECTION N UNKNOWN9 OTHER IV. PIPING INFORMAT ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 UNEDTRENCH A U 95 UNKNOWN A U 99 OTHER A(U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE IPVC) A U 4 FIBERGLASSPIPE C. MATERIAL A 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOLOOMPATIBLEFRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. y P 5 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS AAJ P S 6 PRECISION TESTING P S 7 PRESSURETESTING 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 QLpNTITY OF 3.WAS TAN ,ILLED WITH SUBST �INING IN BALLONS INE L9 ❑YES ❑NO AdA THIS FORM HAS bEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNO WLED E,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# D Z o D o o z CURRENT LOCAL AGENCY FACILITY IDN A PR VED BY AME r//' PHONE N WITH AREA CODE 9(_ PERMIT NUMBER PERMIT APPROVAL A PERMIT EXPIRATION DATE �I CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT p BY: FORM 8(3-7-eel THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORM'A' HAS BEEN FILED DATA PROCESSING_COPY