BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFOR*A WATER RESOURCES CON*L BOARD @. .,•. FORM 'B'- UNDERGROUND STORAGE TANK PROGRAM TN L MTANK PERMIT APPLICATION INFORMATION A" 'K -COPLETE A SEPARATE FORM WITH THE FOLLOWING I ORMATION FOR EACH TANK. 4 MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL SEDTANK 1 ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED �j 9 FACILITY/SITE NAME WHERE TANK IS INSTALLED: -7 FARMTANK-YES❑ NO ❑ G I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY L R A. OWNERS TANK ID p '!q/ B. MANUFACTURED BY: &//C- C. (/LC. YEAR INSTALLED u 0. TANK CAPACITY IN GALLONS: II. TANK TENTS IF(A7),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMC E] 1 UNLEADED LEADED ❑3 DI SEL ❑ B.3 CHEMICAL PRODUCT ❑4 OIL i PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AV,I ATION GAS [D5 HAZARDOUS ❑80 EMPTY [-]95 UNKNOWN E]2 WASTE ❑7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM 0,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.N C.A.S.p' III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D I I.E WALLFD E]3 SINGLE WALLED WITH EXTERIOR LINER E]95 UNKNOWN A TYPE OF ❑ SYSTEM 2 SI WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEBUIRON ❑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 ❑99 OTHER C. INTERIOR ❑ 1 RUBBER UNED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 UC UNING LINING ❑5 GLASS LINING ❑ 6 UNLINED 95 UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? YES ❑ NO 99 OTHER D. CORROSION ❑ 1 PDLYETHLENE WRAP ❑2 iAfl OR ASPHALT ❑3V WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION 91 NONE a95UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE IFABOVEGRU IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 S U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER U 1 STEEL A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 9 NONE C. MATERIAL A M A U 6 CONCRETE A U 7 STEELCLAD W/FRP A U B 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. P 8 UALCHECK P R P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS 8 PRECISIONTESTI 8 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO7YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? E]YES ❑ NO 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 N JURISDICTION N AGENCY N FACILITY ID N TANK ID M m [� Do / els- k 10oo CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE M WITH AREA CODE /0/-)/v TL � `/ PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK N PERMIT AMOUNT CHARGE AMT. FEE CODE R'^ IRT N BY: FOHM B(6-29-M) THIS FORM MUST BE ACCOMPANIED, 'A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA HAS BEEN FILED DATA PROCESSING COPY