BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNU6 WATER RESOURCES CONTROP -OARD a FORM `B': UNDEF�GROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMP TE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY 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 O FACILITY/SITE NAME WHERE TANK IS INSTALLED: ARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY 61 6G A. OWNERS TANK ID R B. MANUFACTURED BY: C. YEAR INSTALLED 197,2— D. TANK CAPACITY IN GALLONS: II. TANK C94TENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COPPLETE ITEM D. F A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM 7k7l'PFODUCT C. UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL ❑4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWNWASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# /" C.A.S.W XIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ LANK N /J SYSTEM ❑ 2 SING AUFD ❑d SECONDARY CONTAINMENTHER �/ STEEIJIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 UEEL CLAD W/FIBERGLASS REINFORCED PUSRC S.TANK MATERIAL ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED 5IEEL ❑ 95 UNKNOWN ❑N OTHER C. INTERIOR F-11 RUBBER UNED ❑2 ALKYD LINING ❑3 EPDXY UNING ❑4 PHENOLIC NING LINING F-15 GLASS UNN4G E]8 UNLINED ❑ IS UNING MATERIAL COMPATIBLE WITH 100KME1HANOL? ❑YES ❑NO W OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TM OR ASPHALT 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODICPROTECTION ❑91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE Am SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSMEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5ALUMINUM A U 6CONCRETE A U 7STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A(995 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. 0V, PS1 VISUAL CHECK P 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P B 5 GROUND WATER MONITORING WELLS P ,6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER . INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USEq NO 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. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY k JURISDICTION k AGENCY k FACILITY ID B TANK ID# D10o o 1 0 CURRENT LOCAL AGENCY FACI�TY ID# APPROVED BY IN PHONE N WITH AREA CODE PERMIT N/l0(IM+sBER LL PERKIT �I1LJ TE (/}SPEP ITEXPIRA DATE 1�1 CHECKR PERMIT AMOUNT SURCHARGE AMT. QfJ FEECODE RECEIPT N BY. U`V\I FORM B(3-7-86) THIS FORM MUST BE ACCO MPAN FACILITY/SITE APPLICATION, FORM7,UNLE NT FORMA• HAS BEEN FILED TCESSING COPY