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 INFORMATIONm COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _ MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑ 7 p MANENTLY CLOSED 7A„, ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE TANK REMOVED Q FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO ❑ 0 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID:# ]]I B. MANUFACTURED BY: y C.YEAR INSTALLED S D. TANK CAPACITY IN GALLONS: OO Fes► II. TANK C TENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT ca MARKED,COMPLETE ITEM D. A- 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM el C. ❑ 1 UNLEADED ❑2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL DOCT ❑4 GASOHOL ❑5 JET FUEL ❑6 AVIATION GAS 5 HAZARDOUS ❑60 EMPTY ❑95 UNKNOWN STE ❑7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# CA.S.#: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,SO A TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM �NGLE WALLED ❑4 SECONDARY CONTAINMENT ❑M OTHER STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CND W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑B 100%METHANOL COMPATIBLE FAP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RUBBER UNE ❑2 ALKYD LINING ❑3 EPDXY UNING ❑4�PHrENOLIC UNING LINING ❑5 GLASS UNING F-16 UNLINED �'Y UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 1010%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑I POLYETHLENE WRAP ❑2 TARORASPHALT ❑3!PMP ❑4 RBERGIASRREINFORCEPLASNC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION f.0l SINGLE WALLED A U 2 DOUBLE WALLED A U 3 UNED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE 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 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. 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS 6 PRECISION TESTING P S 7 PRESSURE TESTING <-P-S 91 NON P S 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 INERT MATERIAL? ❑YES E]NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# = = = 10101 / 160e I c;14 CURRENT LOCAL AGENCY FACILITY ID• APPROVED BY ttAME VQ PHONE WITH AREA CODE � PERMI UMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT I SURCHARGE AMT. FEE CODE RECEIPT# SY: FORM e I6 29-eel THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM `A',UNLESS A RRENT FORM W HAS BEEN FILED DATA PROCESSING COPY