BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD "• FORM 'B': UNDERGROUND STORAGE TANK PROGRAM ., TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z TANK 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 Ip TANK REMOVED Q N FACILITY/SITE NAME WHERE TANK IS INSTALLED: 5O )J FA11M TANK-YES❑ NO [e� � W I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID R B. MANUFACTURED BY: KJ�I W C. YEAR INSTALLED fqbe4 D. TANK CAPACITY IN GALLONS: '-S QC) II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. Ki MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ®3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL R] 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&C.A.S.R C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EKTERIOR UNER ❑95 UNKNOWN SYSTEM Ok2 SINGLE WALLED ❑4 SECONDARf CONTAINMENT ❑99 OTHER ❑i STEBUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CLAD W/RBERGLASS REINFORCED PLASTIC B.TANK F-15 CONCRETE ❑6 POLWNYL CHLORIDE ❑ 7 ALUMINUM ❑8 IW%METHMO�LLC�1OOMPALF�FRP MATERIAL F]9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN �99 OTHER SLf__ 11 F-11 RUBBERUNED ❑2 ALKYD LINING ❑3 EPDXYUNING F-14 PHENOLICUNING C LINING GR ❑ 5 GLASS UNING ❑6 UNLINED ®.95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH 1W%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ 1 POLYETHLENEWRAP ❑ 2 TAR OR ASPHALT ❑ 3 VIW'L WRAP ❑4 FIBEROUWREINFORCEDPLASTIC 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 TYPE A&1 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 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A 6DO5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 RBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A/UT�6�CONCRETE A U 7 STEELCLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL ADM UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION S M MUST BE CIRCLED. r8 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 5 5 GROUND WATER MONITORING WELLS P 5 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS 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 8 SIGNATURE) DATE t LOCAL.AGENCY USE ONLY COUNTY B JURISDICTION R AGENCY# FACILITY ID R TANK ID# ® = = loo2z3 - dao CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME / PNOHE#WITH AREA CODE C LT- �� 1 I PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGEAMT. FEE CODE RECEIPT# BY: 1, FORM 8(6-29-BB) THIS FORM MUST BE ACCOMPANI AFACILITY/SITE APPLICATION, FORM'A7,UNLESS M RENT FORM A• HAS BEEN FILED I DATA PROCESSING COPY