BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNR�, WATER RESOURCES CONTRC IOARD FORM 'B': UNDERGROUND STORAGE TANK PROZaRAM ' TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _� i' MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONE ITEM Ll2 INTERIM PERMIT F-14 AMENDED PERMIT El TEMPORARY TANK CLOSURE E]8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YEP No I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECI Jai N A. OWNERS TANK IDN B. MANUFACTURED BY: N C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: / 4006 H. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. �i MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B C, ❑ 1 UNLEADED 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT F-] 4 OIL 1 PRODUCT ❑ 4 GASAHOL E] 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 CAS,k 6 CAS.P'. A III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,S D A.TYPE OF ❑ I DOUBLEWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 02 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ N OTHER ❑ C.INTERIOR 1 RUBBER LINED ❑2 DLINING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING fi UNLINED ❑95 UNKNOWN - r/ E] IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NOOTHER U/K> D.CORROSION ❑ I POLYETH(ENEWRAP ❑2 TAR OR ASPHALT ❑ 3 LWRAP E]4 FIBERGLASS REINFORCED PLASTIC PROTECTION E] 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN 99 OTHER IV. PIPING INFORMA N 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 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINEDTRENCH 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 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL A 5 UNKNOWN A U 99 OTHER tel. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. S P 1 VISUAL CHECK P 3 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 3 4 ELECTRONIC MONITOR P 3 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. I FORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED ATE LAST USED IMO/YR) 2. ESTIMATED PUANTITY OF 3. WAF TANK FILLED WITH SUBSTAN MAIMING IN GALLONS ATA ATERIAL? E] YES [—] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF EFUURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY M JURISDICTION R AGENCY R FACILITY ID B TANK ID W 1010 a 10 o 111 CURRENT,LOCAL AGENCY FA TTY ID k APPROVED BY N ME PHONE k WITH AREA CODE woo b, C (o Y PERMIT NUMBER PERMIT APPROVAL DATE PEO T EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGEAMT. FEECODE RECEIPTk BY: FORM 8(6-29-w) THIS FORM MUST BE ACCOMPARM dY A FACILITY/SITE APPLICATION, FORM 'A',UNLESSIMORRENT FORMA' HAS BEEN FILED S DATA PROCESSING COPY