BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED , n ONe I �/v FARM TANK-YES4 NO ❑ NO FACILITY/SITE NAME WHERE TANK IS INSTALLED: Z3jO 7 QC I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID p / B. MANUFACTURED BY: C.YEAR INSTALLED r / D. TANK CAPACITY IN GALLONS: 300 IL TANK EONTENTS IF(A-1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. }�X7 A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. 10 C. ❑ 1 UNLEADED 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL PRODUCT ❑<GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) j D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.M: HAZARDOUS SUBSTANCE STORED A C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C.A D A � F-1 1 DOUBLEWALLED F-13 SINGLE WALLED WITH EXTERIOR UNER UNKNOWN TYPESYSTEM ❑2 SINGLEWALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEELARON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL.CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK f7 CONCRETE ❑6 POLYVINYLCHLORIDE U ALUMINUM ❑81W%METHANOL COMPATIBLE FRP ❑ MATERIAL Y�jJ 9 BRONZE ❑18 GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER ❑1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING H ENOUCUNING C.INTERIOR F-1 GLASS UNING ❑6 UNLINED 95 UNKNOWN LINING ❑ ❑IS UNING MATERIAL COMPATIBLE WITH IW%METHANOL? ❑YES ❑NO ❑99 OTHER D.CORRQMON ❑ 1 POLYETHLENEWRAP ❑2 TARORASPHALTINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECT10N ❑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 U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WAILED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM AIfL4 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLEFRP A U 9 GALVANIZEDSTEEL A 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 8 1VISUALCHECK P 8 2 INVENTORY RECONCILIATION P 8 3VADOSE WELLS4ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P IS 7 PRESSURE TESTING P S 91 NONE 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 OALLONS 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 B SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY#® JURII�SDI�CTII�ON# AGENCY N AGILITY ID# TANK ID# IIF l�J CURRENTLO CY FACILITY IDN APPROVED BY NAME PHONE#WITH AREA CODE le f D PERMIT NUYBER YR APPROVAL DATE PERMIT EXPIRATION DAfIf CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT BY: / FORMeIs-z9-66) THIS FORM MUST BE ACCOMPANIEM A FACILITY/SITE APPLICATK)K FORM 'A!,UNLESS A I TORM'N HASBEENFBFD DATA PROCESSING COPY