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BILLING
EnvironmentalHealth
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EHD Program Facility Records by Street Name
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N
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99 (STATE ROUTE 99)
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23597
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2300 - Underground Storage Tank Program
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PR0231606
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BILLING
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Entry Properties
Last modified
11/19/2024 1:54:48 PM
Creation date
11/5/2018 7:52:17 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2300 - Underground Storage Tank Program
File Section
BILLING
RECORD_ID
PR0231606
PE
2381
FACILITY_ID
FA0003860
FACILITY_NAME
DAUSE, BILL*
STREET_NUMBER
23597
Direction
N
STREET_NAME
STATE ROUTE 99
City
ACAMPO
Zip
95220
CURRENT_STATUS
02
SITE_LOCATION
23597 N HWY 99
P_LOCATION
99
P_DISTRICT
004
QC Status
Approved
Scanner
SJGOV\rtan
Supplemental fields
FilePath
\MIGRATIONS\N\HWY 99\23597\PR0231606\BILLING .PDF
QuestysFileName
BILLING
QuestysRecordDate
10/18/2017 10:02:14 PM
QuestysRecordID
3688675
QuestysRecordType
12
QuestysStateID
1
Tags
EHD - Public
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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> r . <br /> FORM `B': UNDERGROUND STORAGE TANK PROGRAM fo <br /> TANK PERMIT APPLICATION INFORMATION <br /> TANK <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> r� <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT Et�CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED /S <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: f ^FARM TANK-YES❑ NO N <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY <br /> A. OWNERS TANK ID# B. MANUFACTURED BY: co <br /> C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: <br /> If. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL <br /> ❑3 CHEMICAL PRODUCT ❑ 4 OIL ❑ 1 PRODUCT ❑ 4 GASAHOL 5 JET'FUEL 6 AVIATION GAS <br /> © 5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ®2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D <br /> A.TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM ❑ 2 SINGLEWALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER <br /> ❑ 1 STEELIIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC <br /> B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP <br /> MATERIAL <br /> 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN 99 OTHER <br /> ❑ 1 RUBBER LINED F-12 ALKYD LINING F-13 EPDXY LINING ❑ 4 PHENOLIC LINING <br /> LINING <br /> C. INTERIOR 5 GLASSUNING 6 UNLINED 95 UNKNOWN <br /> ❑ ISUNINGMATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER <br /> D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OA ASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> 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 <br /> 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 <br /> 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 <br /> C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADWIFRP A U B 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS <br /> P S 6 PRECIS'ON P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER <br /> V1. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES E] NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> EPERMIfNURfSER <br /> JURISDICTION# AGENCY# FACILITY 10# TANK ID# <br /> = I I 1 :1 1 1 1 1 ILL 17(� I I E I I El <br /> AGENCY FACILITY ID N APPROVED BY NAME PHONE k WITH AREA CODE <br /> Dal <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE IbAsPERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: <br /> i <br /> FORM B(6-29-68) THIS FORM MUST BE ACCOMPA D BY A FACILITYISITE APPLICATION, FORM 'A',UNLES CURRENT FORMA` HAS BEEN FILED <br /> DATA PROCESSING COPY <br />
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