BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

-- -- Y STATE OF CALIFORNIAS WATER RESOURCES CONTRORD FORM `B': UNDE GROUND STORAGE TANK PROanm TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. iC MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE E 'T K REMOVED O 9 �� p IV FACILITY/SITE NAME WHERE TANK IS INSTALLED: 35 L_0 UY Lsn FARM TANK-YES❑ NO ❑ A LVI I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID 4 bwLola(p5 to CSO I B. MANUFACTURED BY: C.YEAR INSTALLED akk— D. TANK CAPACITY IN GALLONS: I(}uu II. TANK CONTENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADEDEADED ❑3 DIESEL ❑ 3 CHEMICALPRODUCT ❑ 4 OIL 1 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 8 CA S.# C.A.S.k: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A.TYPE OF ❑ 1 DOIIBLEWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEMGLEWALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER QJ B&EEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/RBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑B IDA METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN �OTHER LA k ❑ C. INTERIOR i RUBBER LINED ❑ 2 ALKYD LINING F--] 3 EPDXY LINING [:] 4 PHENOLIC LINING " LINING ❑5 GLASS UNING ❑ 6 UNLINED �WN ❑ IS LINING MATERIAL COMPATIBLE WITH IDA METHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ I POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 RBERGLASS 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 U 1 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 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U S 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 ACONCRETE A U 7 STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 5 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 5 1 VISUAL CHECK P 3 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P S 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. APPLICANT'S NAME(PRINTED 8 SIGNATURE DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION R AGENCY 8 FACILITY ID R TANK ID N CURRENT LOCAL AGENCY FACILITY ID N ,� APPR= PHONE 0 WITH AREA CODE PERMIT NUMBER /u` I,^, PERMIT APPROVAL DATE PERMIT EXPIRATION DATE 1 CHECK M PERMIT AMOUNT SURCHARGE AMT. FEE CODE L.R.ECEIPT• BY: A16 ,, FORM B(6-29-ee) THIS FORM MUST BE ACCOMPANY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A RENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY