BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

iTATE OF CALIFORNIA WATER RESOURCES CONTROL;"" �f►RD FORM 'S': UNDERGROUND STORAGE TANK PRO M = 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 ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED CJI17 b, C N FACILITY/SITE NAME WHERE TANK IS INSTALLED: � � FARM TANK-YES❑ N co I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY 4bb A. OWNERS TANK ID# B. MANUFACTURED BY: rjEA) ^(5— C YEAR INSTALLED D. TANK CAPACITY IN GALLONS: ODCD II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 01 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. IJ ' UNLEADED ❑ 2 LEADED ❑ 3 DIESEL - ❑3 CHEMICAL PRODUCT ❑4 OIL J2 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATIONGAS ❑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 C.A.S.#: HAZARDOUS SUBSTANCE STORED A C.A.S.# III. TANK CONSTRUCTION MARK ONE AM ONLY IN BOX A,B,C,A D A.TYPE OF ❑�I DOUBLEWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM u 2 SINGLEWAUED ❑4 SECONDARY CONTAINMENT ❑99 OTHER [ErSTEEL/IRON ❑ 2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4MEL CLADW/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑S 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑W OTHER ❑ 1 RUBBER UNED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING [6 UNLINED ❑95 UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO E199 OTHER f D. CORROSION F--] LTJ 1 POLYETHLENE WRAP 2 TAR OR ASPHALT ❑3 VINYL WRAP ❑ 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'n A43 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A kA SINGLE WALLED A U 2 DOUBLE WALLED A Ul 3 LINED TRENCH A U 91 NONE 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 A U 91 NONE C. MATERIAL A U 5 ALUMINUM A A.6 CONCRETE A U 7 STEEL CLAD W/FRP A U 81 DO%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL U 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. S P 1 VISUAL CHECK P 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS � P 8 6 PPECISIDN TESTING 8 ] PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P 6 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE ST USED(MO/YR) 2.ESTIMATED OUANTITY OF 3.W TANK FILLED WITH I 4 / /� SUBST REMAINING IN �MATERIAL? F]YES ❑NO fv �L GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY 6F 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 ID# TANK ID# 10 lo 111CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NA7a_7 PHONE WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DA E PERMIT EXPIR TION DATE CHECK# PERMIT AMOUNT iURCHARGEAMT. FEE CODE RECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BTA FACILITY/SITE APPLICATION, FORM 'A',UNLESS A RENT FORMA' HAS BEEN FILED I, DATA PROCESSING COPY