BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNALO WATER RESOURCES CONTRL#BOARD FORM V: UNDERGROUND STORAGE TANK PROGRAM Qp TANK TANK PERMIT APPLICATION INFORMATIOCOMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION 10 ONE ITEM ❑ 7 PERMANENTLY CLOSED TANK ❑21NTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE L K REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 1 � WK-YES❑ NO (� 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID q I B. MANUFACTURED BY: N C. YEAR INSTALLED /7t33 D. TANK CAPACITY IN GALLONS: V0 II. TANK CONTENTS IF(A7),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 01 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED 3 DIESEL ❑3 CHEMICAL PRODUCT ❑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&C.A.S.# A C.A.S.#: 14 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,0,C,8 D A.TYPE OF Q,1DOUBUE WADED ❑3 SINGLE WALLED ATH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 81RGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEEL/IRON ❑2 STAINLESS STEEL E]3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.MATERIAL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER C. INTERIOR E] 1 RUBBERLINED ❑2 A LINING ❑3 EPDXYLINING ❑4 PHENOLIC LINING LINING ❑5 GLASS UNING 'SUNLINED ❑95 KNOWN A ❑ ISUNING MATERIAL COMPAT18LE WITH IOD%METHANOL' [:]YES ❑ NO 990THER ✓`-A D.CORROSION ❑ 1 POLYETHLDIE WRAP 2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 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 ALg4 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A w 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 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. j` ' S VISUAL CHECK S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P B 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS `�T/ 6 PRECISION TESTIN P S 7 PRESSURE TESTING 91 NONE P 8 95 UNKNOWN P S 99 OTHER VI. &FORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAST NK FILLED WITH SUBS A EMAINING IN E IAATERIAL9 yES ❑ NO GALLONS y-� THIS FORM HAS BEEN COMPLETED UNDER PENALTY OP PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# �URISDICTmON# AGENCY# FACILITY ID# TANK ID# D M p ff;;L ID 4 APPROVED BY E JJ PHONE#WITH AREA CODE PERMIT APPROVAL DATE PERMITE PIRATION DATE UNT SURCHARGE AMT. FEE CODE RECEIPT# Ry; FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIE BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A M RRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY -