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 ;a MARK ONLY ❑ 1 NEWPERMIT ❑3 RENEWALPERMIT15 CHANGE OF INFORMATION E] 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDEDPERMIT J LTJ 6�TEMPORARY TANK CLOSURE 6 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NOfq I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY p A. OWNERS TANK IDN B. MANUFACTURED BY: Sr C. YEAR INSTALLED 19 D. TANK CAPACITY IN GALLONS: 5_4 idtGdl� W II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,Q&PLETE ITEM D. (� A. 61MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. X 1 UNLEADED ❑2 LEADED ❑3 DIESEL ' 3 CHEMICAL PRODUCT ❑ 4 OIL ❑ 1 PRODUCT ❑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.AS.p: XIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.&D 1 UBLE WALLED ❑3 SINGLE WALLED WITH EXTEROR UNEP F-195 UNKNOWN A. TYPE OF ❑ SYSTEM LV 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEELIRON ❑2 STAINLESS STEEL [—]3 FIBERGLASS ❑4 STEEL CUD W/RBERGLASS REINFORCED PLASTIC B.TANK MATERIAL F-15 CONCRETE ❑6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑B 100%METHANOLOOMPADBLEFRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RIBBER UNED ❑2 ALKYD LINING ❑3 EPDXY UNING ❑4 ENOLICUNING LINING ❑ 5 GLASS LINING ❑6 UNUNED MOWN ❑IS LINING MATERIALOOMPADBLE WITH 100%METHANOL? [:]YES ❑ NO OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL WRAP F-14 FIBERGLASS REINFORCED PLASTIC PROTECTION [—] 5 CATHODIC PROTECTION E]91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE & SYSTEM TYPE A 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 LINED TRENCH A 1US UNKNOWN A U 99 OTHER A 0 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 STEELCLADW/FRP A U B 10D%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER I,V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION 8 3 VAGOSE WELLS P 9 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS 6 PRECISION TESTING P B 7 PRESSURE TESTING P 91 NONE P S 95 UNKNOWN P 8 99 OTHER I. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED N DATE LAST USED(MO/YR) 2.ESTIMATED QUANTITY OF 3, WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES ❑ NO THIS FOR HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. A (CANT'S NAME(PRINTED B SIGNATURE) DATE 2 /9 &' LOCAL A USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID M EK = = lqlvl7loL57fa 1 lololo ,2 CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE N WITH AREA CODE MIS 2 l) �_S PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT _ SURCHARGE AMT. I FEE CODE RECEIPT# BY: FORM B I3-7-SB) THIS FORM MUST BE ACCOMPANIED BY A FACIL(TY/SITE APPLICATION, FORM'A',UN A CURRENT FORMA' HAS BEEN FILED . DATA PROCESSING COPY