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 TANK C`l COMPLETE A SEPARATE FORM WITH THE FOLLOWING ORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑ O RENEWAL PERMIT 26 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSEDTANK ONE ITEM [:] _2 INTERIM PERMIT ❑/AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED U FACILITY/SITE NAME WHERE TANK IS INSTALLED: -/ FARM TANK-YES NO ❑ I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A OWNERS TANK IDI .,)- 1 B. MANUFACTURED BY: V( C. YEAR INSTALLED U&_ 1 D. TANK CAPACITY IN GALLONS: If. TANK ONTENTS IF(A.1),18 MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A I MOTOR VEHICLE FUEL ❑2 PETROLEUMB. C. ❑ i UNLEADED 2 LEADED ❑ O DIESEL ❑0 CHEMICAL PRODUCT E]1 OIL PRODUCT ❑/ GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ OO 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 6 C.A.S.I - CA.S.V: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOR A.8,C.S D A TYPE OF ❑PDOUW Wim ❑S SINGLE WALLED WITH EXTERIOR UNER ❑%UIMNOWN SYSTEM ?'ww WALED ❑/SECONTAIN CONTAINMENT ❑99 OTHER Ez'l STEEU4 DN ❑2 STAINLESSSTEEL ❑B RBEROLASS ❑1 STEEL CLAD WIFIBERGUSS REIMOCEO PLASTIC S.TANK ❑5 CONOETE ❑ 6 POLYVINYL CFEORIDE ❑7 ALUMINUM ❑ 6 IDB%METHANOL COMPATIBLE FAP MATERIAL ❑9 BRONZE ❑ IO GALVANIZED STEEL ❑25 UNKNOWN ❑99 OTHER ❑ I RIOBERUNED ❑2 AM LINING ❑ 7 EPDXY UNNG ❑/ NOLICUNING C.INTERIOR LINING ❑ 5 GLASSLNNG ❑6 UUMD %UIMIKIWN IS LINING MATERIAL COWATRE WITH IOD%METHANOL? ❑YES ❑ NO El 99 OTHER D.CORROSION ❑ 1 POLYETIEENEwRAP ❑2 TAR OR ASPHALT ❑VMaWRAP ❑/FIBERGLASS REINFORCED PLASTIC PROTECTION [:] 5 CATHODIC PROTECTION ❑91 NONEEB'95UNXNM ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 9 GRAVITY A U 91 NONE A U 9 A U 99 OTHER B.CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 9 LINED TRENCH A U 91 NONE A U 9 UNKN WN U 99 OTHER A U I STEELARON A U 2 STAINLESSSTEEL A U 9 POLYVINYL CHLORIDE(PVC) A U I FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5ALUMINUM A U 6 CONCRETE A U ISTEELCIADW/FRP A U 8190%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U NKN WN 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 t 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P t 9 VADOSE WELLS ► 8 1 C MONITOR ► 8 5 GROUND WATER MONITORING WELLS P t. 6 PRE,$,= ► 8 7 PRESSURE TESTING P t 91 NONE P 95 UNKN I t 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST U$ED(MO/YRI 2. ESTIMATED QUANTITY OFOALLONt D.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PER)URY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPUCANT'S NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY I JURISDICTION # AGENCY 6 FACILITY ID I TANK ID CURRENT LOCAL AGENCY FACILITY ID I APPROVED BY NAME PHONE I WITH AREA CODE 13/z 19A) X1-0 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE I CHECK\ PERMIT AMOUNT SURCHARGE AMT. FEE CODE .... RECEIPT I BY: C ...........,...• T119[?TOM MIIXT RL IPPGY0IMICD RY\C\NI IYVMItt\MI Isamu C/lD V 'A. um eee.,.nn..eu. .......... ................