BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNI w WATER RESOURCES CONTRC IOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION mr COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. :A MARK ONLY ❑ 1.NEW PERMIT ❑3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL K ONE ITEM 11R1,2 INTERIM PERMIT F-14 AMENDEDPERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVE FACILITY/SITE NAME WHERE TANK IS INSTALLED: LA) , FARM TANK-YES❑ NO z I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 10 A. OWNERS TANK ID# 6 j,.... B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: W II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. C. ❑ 1 UNLEADED L] 2 LEADED DIESEL �. F-13 CHEMICAL PRODUCT ❑4 OIL 1 PRODUCT ❑ 4 GASAHOL ❑5 JET FUEL ❑6,AWATION GAS ❑5 HAZARDOUS 80 QMPN ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑99 OTHER(D,FACRIBE IN ITty OW) D. IF NOT MOTOR VEHICLE FUEL,EN ER NAME OF /1 HAZARDOUS SUBSTANCE STORED&C.A.S.# Azl .1 C.A.S.#: 1L1 Xlll. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&o A � F-11 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWNTYPE I, ' SYSTEM t P SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER J 1 STEEL/IRON P,.. ❑2'STNNLESS STEEL ❑ 3FIBERGLASS ( ❑4STEEL CUDW/FIBERGLAS6 REINFORCED PLASTIC B.TAMC F-1 5 CONCRETE I rL) 1`` ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP f .. MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑,115 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBEfl LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING. r _� C. INTERIOR py c -- - LINING ❑ 5 GLASS LINING 6�J°UNUNED ❑ 95 UNKNOWN ❑IS UNING MATERIAL COMPATIBLE WITH 1W%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2TAR OR ASPHALT ❑3VINYL WRAP ❑4FlBERGLA66 REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑99 OTHER J IV. PIPING INFORMAT ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U I SUCTION ..A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER f B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A '99 OTHER A U I STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE IPVC) A U 4 FIBERGLASS PI, C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 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. L/ v S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRDyJC MONITOR P S 5 GROUND ITER MONITORING WELLS 7 P 5 6 PRECISION TESTIN S 7 PRESSURE TESTING P S 91. NONE- _P S 95 UNKN(kC N P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED19PLACE 1. ESTIMATE DATE LAST USED(MO/YR) 2. ESTIMAIV QUANTITY OF 3. WAS TArt FILLED WITH SUB T EMAIMING IN GALLONS INR TA IAL? I YES ❑NO THI F RM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) I. - DATE 1 ri LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 1010 1 -4 216171 1 dO0 CURRENT OCAL AGENCY FACILITY ID# APPR ED BY AMEE / PHONE#WITH AREA CODE / X - / �O (� PERMIT NUMBER PERMIT PERMIT EXPIRATION DATE \ J GNECK# PERYIT AMOUNT SURCHJUIRIEA . FEE CODE RECEIPT# BY: FORMB(3-7-88) THIS FORM MUST BE ACCOMPANIEDBYA FACILITY/SITE APPLICATION, FORM `A,UNLESS A CURRENT FORMA' HASBEENFILED DATA PROCESSING COPY