BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNI/ WATER RESOURCES CONTRO DARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION m COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 'L MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDEDPERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED W FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK.YES O N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY CA CJ1 A. OWNERS TANK ID N in 8. MANUFACTURED BY: r 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. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL ❑ 1PRODUCT ❑4 GASOHOL ❑ 5 JET FUEL ❑6 AVIATION GAS E]5 HAZARDOUS ❑ 80 EMPTY UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF 'A kI/ C HAZARDOUS SUBSTANCE STORED 8 C.A.S.# '✓ - - C.A.S.11: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A.TYPE OF ❑ 1 DOUBLEWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINERUNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEELIIRON ❑2 STAINLESS STEEL ❑3 RBERGUSS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALU ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑99 OTHER C. INTERIOR F-] 1 RUBBER UNED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PH INING LINING ❑ 5 GLASS LINING ❑6 UNLINED Eli UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TARORASPHALT ❑3 A ❑ 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 A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A95. OWN 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 LINK OWN A U 99 OTHER A U 1 STEEL/IRON 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 U fi A U 7 STEELCLADW/FRP A U S 10D%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 95 UNKN 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 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 6 4 ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P B 95 UNKN W P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED OUANTITY 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. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY TDF TANKID# CURRENT LOCAL AGENCY FACILI�D#/1APPROVED BY NAME PHONE F WITH AREA CODE PERMIT NUMBER KK PERMIT APPROVAL DATE PERMIT EXPIRATION DATE ICHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORV B(6-29-63) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY