BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORN _ WATER RESOURCES CONTR_ BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM M1f 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 MANENTLV CLOSED TANK G ❑ ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE TANK REMOVED 1 C ONE ITEM 21NTERIM PERMIT FACILITY/SITE NAME WHERE TANK IS INSTALLED: D FARM TANK-YES NO ❑ Cyl I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY �! A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),18 MARKED,COMPLETE ITEM C.IF(A7),IS NOT MARKED,COMPLETE ITEM D. A. i MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ I UNLEADED 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL 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 d C.A.S.# CA.S.M Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.a D A TYPE OF ❑I WN l m ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEMLST7SINGLEWALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER STEEL/IRON 2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE RIP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER G INTERIOR F-11 RUBBER LINED F]2 ALKYD LINING F-13 EPDXY UNING ❑4 PHENOUC LINING LINING ❑5 GLASS UNING TUNED ❑95 UNKNOWN ❑IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHUTIEWRAP ❑2 TARORASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC 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 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 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER ASTEEL/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 A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8109%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL 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 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING Z52zf91 NONE P 8 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. APPLICANTS NAME(PRIMED S SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# m lo o / CURRENT LOCAL AGENCY FACILITY ID# APPROVED B NAME PHONE#WITH AREA CODE da4ea -77f d PERMIT NUMBER PERMIT APPROVAL DATE PfRMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGEAMT. FEE CODE RECEIPT BY: FORM B(6-29-36) THIS FORM MUST BE ACCOMPANI Y A FACILITY/SITE APPLICATION, FORM 'A',UNLESS RRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY