BILLING_1985-2000 - Laserfiche WebLink

Home Browse Search

.STATE OF CALIFORNJ6 WATER RESOURCESCONTRffOARD FORM 'B': UND GROUND STORAGE TANK PR RAM '- TANK TANK PERMIT APPLICATION INFORMATION m ° m3 COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 4 _ z IG MARK ONLY 1 NEW PERMIT [-] 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY C NK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑6 TANK REMOVELod N FACILITY/SITE NAME WHERE TANK IS INSTALLED:ICI jqjE� FARM TANK-YES❑ NO .A W 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY j1 A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: O 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. K;] 1_MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED2 LEADED ❑ 3 DIESEL �II F-] 3 CHEMICAL PRODUCT ❑ 4 OIL ��RODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ISO, ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) S/ D. IF NOT MOTOR VEHICLE FUEL,ENTER NAMEC. OF HAZARDOUS SUBSTANCE STORED& A.S.# A--"IA C.A.S.#: A III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF ❑�I DOUBLEWALLED F-]3 SINGLE WALLED WITH EXTERIOR LINEA ❑95 UNKNOWN SYSTEM Iv `SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER I STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD WIFIBERGLASS 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 ❑ I RUBBER UNED ❑2 ALKYO LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING UNLINED ❑ 95 UNKNOWN 1� ❑ IS LINING MATERIAL COMPATIBLEWITHIDD%METHANOL? ❑YES [:] NO Nr99OTHER LINK D.CORROSION ❑ 1 POLYETHLENE WRAP 2 TAR OR ASPHALT ❑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 A. SYSTEM TYPE A Q1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A 61,1 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 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM AU 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 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 2 INVENTORY.RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS S 6 PRECISION TESTING 5 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P 6 99 OTHER V1. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USE (MO/ R) 2. ESTIMATED QUANTITY OF 3.WASTAlf FILLED WITH SUBSTANIN � IN YES ❑4/ p Cx GALLONS NO THIS FORM HAS BE N C MPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLE GE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# da � 60 � 0643 CUflR }p AGENCY ID# APP VED B ME PHONE#WITH AREA CODE S 1 PERMIT NUMBER PERMIT A PRGLSTE PE IT EXPIRATION DATE ` \ [CH K* PERMIT AMOUNT URCHARGE A .l FEE CODE CEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY