BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFO#A WATER RESOURCES COL BOARD ° FORM V: UNDERGROUND,STORAGETANK OGRAM TANK PERMIT APPLICATION INFORMATION ' TAN K+ -- - --- -- - - t q>1 L vmrLe I E A SEPARATE FORM WITH THE FOLLOW TG INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT HANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE NK ONE ITEM V2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED��FARM TANK -YES ❑ NOFACILITY/SITE NAME WHERE TANK IS INSTALLED: L'.4 2w-A_� FARM TANK -YES NO I. TANKDESCRIPTION COMPLETE ALL ITFMS_IFIIMNNl1WN—an 000clev A. OWNERS TANK ID # 01 B. MANUFACTURED BY: C. YEAR INSTALLED 11-71 ID. TANK CAPACITY IN GALLONS: 2- D(76 II. TANK CONTENTS IF IA.11. IS MARKED_ COMPI FTF ITFM C IF lA ll IS MOT YAOYGn CnYOI FTF lieu n A.1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM e. C. Er1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL F-13 CHEMICAL PRODUCT ❑ 4 OIL f�l1 PRODUCT ❑ 4 GASAHOL [:]5 JET FUEL E]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 & C.A.S. # C.A.S. #: y A ❑ 2 STAINLESS STEEL III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, & D A TYPE OF ❑ 1 DOUBLE WALLED 2 ❑ 3 SINGLE WALLED WITH EXTERIOR UNER ❑ 95 UNKNOWN SYSTEM � SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER A ET�,SrEEUIRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8100% METHANOL COMPATIBLE FRP U 3 LINED TRENCH A U 91 NONE ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR F-11 RUBBERLINED ❑ 2 A LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING F-]5 GLASS LINING 6 UNLINED C. MATERIAL ❑ 95 UNKNOWN U 5 ALUMINUM A ❑ SLIMING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 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 AGENCY # FACILITY ID # 10101 1? TANK ID # lol U A. SYSTEM TYPE A U 1 SUCTION A U PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER -DATE B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A /V� 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 1 OM METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U"J95 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 S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P� I PRECISION TESTIN P 8 ]PRESSURE TES TI NG P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSEe IN PLACE 1. ESTIN D DATE LAST USED (MO/YR) 2. ESTIMAT QUANTITY OF 3. WAS A K FILLED WITH ��1// SU; CFj(iEMAINING IN TERIAL7 ❑ YES ❑ NO V ILI GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY F PERJURY. AND TO THE BEST OF MY KNOW) FncF IR TRI IF ANn rnalaFnr APPLICANT'S NAME (PRINTED & SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY # JURISDICTION # AGENCY # FACILITY ID # 10101 1? TANK ID # lol U CURRENT LOCAL AGENCY FACILITY ID L APPROVED BY N U�E^^ PHONE # WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE I IPERMfTEXPIRATIO -DATE CHECK# PERMITAMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: ��n,ol�-�=-ppl „,p wNm,ew,pc NeeVwrMnILV PTRrAWLIITIJIIEAFPLII.ALvN, rumm-A,UNLESSACURRENT FORMA' HASBEENFILED DATA PROCESSING COPY z 10 m 00 C11 (40 JI