BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORN' WATER RESOURCES CONTR BOARD "•T FORM 'S': UNDERGROUND STORAGE TANK PROGRAM < �� TANK PERMIT APPLICATION INFORMATION ,y ° J' TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z 10 MARK ONLY ❑ I NEW PERMIT ❑3 RENEW AL PERMIT RANGE Of INFORMATION ❑ 7 P NENTLY C NK ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT JJ ❑6/TE'M'PORARY TANK CLOSURE 6 TANK REMOVED Q W FACILITY/SITE NAME WHERE TANK IS INSTALLED: �� !/✓. y(S GOD �� FAR TANK-YES❑ NO 1, N J � 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY CD Co A. OWNERS TANK IDN B. MANUFACTURED BY: - C. YEAR INSTALLED D. TANK CAPACITY IN GALLON . S G U II. TANK ONTENTS IF IA.1),18 MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE A. 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED 3 SEL ❑3 CHEMICAL PRODUCT ❑4 OIL I PRODUCT ❑ N GASAHOL ❑ 5 JET FUEL 6 AVIATION GAS ❑5 HAZARDOUS ❑ BO EMPTY ❑ 95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM O BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C.A.S.N C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C.A D A.TYPE OF ❑ I DOUBLEWALLED ❑ 3 SINGLE WADED WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑/SECO10M CONTAINMENT ❑99 OTHER ❑ I STEEURON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 1 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC S.TANK ❑ S=am ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 6 190%METHANOL COMPATIBLE fRP MATERIAL . ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 lN9NN0VIN ❑ 99 OTHER C.INTERIOR ❑ I RIBBER LNf➢ ❑ 2 AUAYD LINING ❑3 EPDXY UNING ❑ 1 PHENOLIC LINING LINING ❑5 GLASS LINING ❑6 UNLINED ❑95 UNKNOWN ❑ IS UNNG MATERIAL COMPATIBLE WITH IDU%METIW400 ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ I POLYEREENEWRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑/FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 GTHWICPROTECTI N ❑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 I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U I 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 I STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U A FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U B 100%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 LEAK DETECTION SYSTEM MUST BE CIRCLED. P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S I ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I. ESTIMATED DATE UST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑NO GALLONS 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 N JURISDICTION N AGENCY N FACILITY ID N TANK IO N Z '67 5 D Io 16 CURRENT LOCAL AGENCY FACILITY ID F / APPROVED BY NAME PHONE F WITH AREA CODE PERMIT NUMBER `.'^L/'I•fA� PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE AECEIPT N FORM B(6-2966) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED \. nn�-n aanrcc c..,r nnn..