BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM o TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION � 7 P MANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE TANK REMOVED U' FACILITY/SITE NAME WHERE TANK IS INSTALLED: V- FARM TANK-YES❑ NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN 40 SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: 14 W G. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: / IL TANK CPNTENTS IF(AA),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. 1 UNLEADED 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT 4 OIL rwA, ODUCT ❑4 GASAHOL ❑5 JET FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS BD EMPTY ❑95 UNKNOWN ❑ STE ❑ 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) �i D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.If C.A.S.#: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN SOX A B,C,&D A TYPE OF ❑ 1 BLEWAU-ED 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM L lfl SINGLE WALLED 4 SECONDARY CONTAINMENT ❑99 OTHER STEBUIRUN ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYWNYL CHLORIDE ❑7 ALUMINUM ❑B IW%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN 99 OTHER C INTERIOR F-] 1 RUBBER UNED ❑2 AUKGWNING F-13 EPDXY LINING E]4 PHENOLIC LINING LINING ❑5 GLASS LININGMINED ❑95 UNKNOWN ❑ ISUNINGMATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER I POLYETHENEWRAP 2TAR OR HALT D. CORROSION ❑ ❑ ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC 0 PROTECTION ❑5 CATHODIC PROTECTION NE ❑ 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER AV STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A 5ALUMINUM A U 6CONCRETE A U 7STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP j 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 A/ : 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS P S PRECISION TESTIN 6 ]PRESSURE TE STING P S 91 NONE P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED OUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES E] NO SALOONS i THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF 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# = = Od / 5F 6 CURRENT LOCAL AGENCY FACILITY ID# APPROVED B NAME 1 V PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMt EXPIR TION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEECODE RECEIPT# BY: FORM B(e-29-w) THIS FORM MUST BE ACCOMPANIEL,.A FACILITYISITE APPLICATION, FORM `A',UNLESS A dVnENT FORM'A' NAS BEEN FILED 'T DATA PROCESSING COPY