BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNI P WATER RESOURCES CONTRO' 90ARD FORM 'B': UNDEWGROUND STORAGE TANK PROuRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 300 ("� �y(/(yL�tJ .Ln . FARM TANK-YES❑ M0 %2dZ I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY IO A. OWNERS TANK ID# B. MANUFACTURED BY: u'k C. YEAR INSTALLED i. 7 D. TANK CAPACITY IN GALLONS: / 01000 GL) II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM 0. cy) A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL �RODUCT ❑ 4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY ❑ 95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF HAZARDOUS SUBSTANCE STORED&CAS.# C.A.S.#: XIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.IS,C.&D A.TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM Y2 SNGLEWAUID ❑4 SECONDARICOMAIWENT ❑%OTHER 1 $TEDUIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL F-15 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑B 10D%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR F-] 1 RUBBER LINED ❑2 MOD LINING ❑3 EPDXY LINING F-14 PHENOLIC LINING LINING F-15 GLASS UNING ❑6 UNLINED �UNKNOWN [-] IS UNING MATERIAL COMPATIBLE NTH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑TT--1/3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION [-]5 CATHODIC PROTECRON ❑91 NONE I�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 W OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A(U)95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLAD W/FRP A U B 100%METHANOLCOMPATIBL FRP A U 9 GALVANIZEDSTEEL A C095 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 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 6 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 ❑ 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 9 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CURRENT LOCAL AGENCY FACILITY 10# APPROVED BY NAME PHONE#WITH AREA CODE to c' 0 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMITAMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: V FORM B(3-7-86) THIS FORM MUST BE ACCOMPANIED BV A FACILRYISITE APPLICATION, FORM 'A',UNLESS ftIRRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY