BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM ` TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. __ Z MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK 10 ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURETANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES NO ❑ I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID N / B. MANUFACTURED BY: C YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF( .1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ ETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 0 ❑ 1 PRODUCT ❑ 4 GASAHOL ❑5 JET FUEL ❑ 8 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EM ❑ 95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,80.0W) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAM OF HAZARDOUS SUBSTANCE STORED&C.A.S.N C.A.S.W III. TANK CONSTRUCTION MARK ONE NM ONLY IN BOX A,B,C,&D A. TYPE OF ❑ I DOUBLE WALLED ❑3 SING WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECOND CONTAINMENT ❑99 OTHER ❑ 1 STEEL/IRON ❑2 STAINLESS ❑ 3 PEER GLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑8 POLYVINYL CHLO E ❑ 7 ALUMINUM ❑81W%METHANOLOOMPATIBLEFAP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZEDMEL ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR F-11 RUBBER UNE ❑ 2 ALKYD LINING 3 EPOWUNING F-14 PHENOLIC LINING LINING F-15 GLASS LINING ❑6 UNUNE [:] 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH IOD%MEfHANOL? ❑Y ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TARORASPHALT ❑3 VINYL 1:14 FIBERGLASS REINFORCE PLASTIC PROTECTION [:] 5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUN BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAM 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 TREfXH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYLC RIDE(PVC A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5ALUMINUM A U 6CONCRETE A U 7STEEL CLAD W/ A U 8100%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 EAK DETECTION SYSTEM MUST BE CIRCLED. P SI VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MON OR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95t P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WA ANK FILLED WITH SUBSTANCE REMAINING IN INERT GALLONS ATERIAL? 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID N TANK ID N 60 / I Lo 51 1010101 / 1 CURRENT LOCAL AGENCY FACIL I;p/ VED BYlNNAME PHONE N WITH AREA CODE PERMIT NU BER PERMIT AP4APPRO DATE PER EXPIRATION DATE CHECK p PERMIT AMOUNTI SURCHARGE AMT. FEE CODE RECEIPT• BY: FORM B(6-29 eel THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS AteRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY