BILLING_PRE 2109 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA WATER RESOURCES CONTROL B'- ^RD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION ° COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. z 10 MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT a5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMITT ❑8 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED T-, FACILITY/SITE RAMP.WHERE TANK IS INSTALLED: q -,&/ eveO. Pod FARM TANK-YES❑ NO ❑ Tv I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY W A. OWNERS TANK IDE B. MANUFACTURED BY: C. YEAR INSTALLED ', �G , D. TANK CAPACITY IN GALLONS: O 11. 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. ❑ I UNLEADED ❑ 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT OIL ❑ 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑8 AVIATION GAS ❑5 HAZARDOUS ❑SO EMPTY ❑95 UNKNOWN �2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM 0,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.E C.A.S.E: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN SOX A.e,C,d D A TYPE OF 0 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ; UNKNOWN SYSTEM ❑2 SINOLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ I STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑A POLYVINYL CHLORIDE ❑1 UMINUM ❑B IAD%METHANOL COMPATIBLE FRP MATERIAL ❑9 BDIRE ❑ 10 GALVANIZED STEEL %lEA(NOYM ❑H OTHER C.INTERIOR [:] I RIISBER LINED ❑2 ALKYD LINING ❑ E]3 EPDXY LINING 4 IC LINING LIMING ❑5 GLASS LINING ❑A UAlNEO %UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH 1011%METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ I POLYETHLENEWRAP ❑2 TARORASPHALT ❑3r WRAP ❑ (FlBERGLASS REINFORCED FUSTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE %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 <ICED 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 TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEUIRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U A CONCRETE A U 7 STEELCLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEE9ZEnrV5 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,ORS FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P A 1 VISUAL CHECK P P. 2 INVENTORY RECONCILIATION P 6 3 VADOSE WELLS 0 3 4 ELECTRONIC MONITOR P B 5 GROUND WATER MONITORING WELLS P A A PRECISION TESTING P B 7 PRESSURE TESTING P E 91 NONE UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE UST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN OALLONE 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 A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY E JURISDICTION E AGENCY E FACILITY ID E TANK ID E 3 G10 10 CURRENT LOCAL �AGENCY FACILITY ID E APPROVED SY NAME PHONE#WITH AREA CODE 6..i..-.. V 61 I PERMIT NUMBER PERMIT APPIDVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT BIIRCHARDE AMT. FEE CODE RECEIPT# BY: FORMS(S-29-6 THIS fORM MUST BE ACCOMP ..DBTAFACILITY/SI TE APPLICATION, FORM 'A',UNUJiCLREBW FORMA' HASBEENFILED DATA PROCESSING COPY