BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA WATER RESOURCES CONTR(".?OARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION }gym COMPLETE A SEPARATE FORM WITH THE FOLLOWIN INFORMATION FOR EACH TANK. _ - Z' 10 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT Evf5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE T ONE ITEM ❑ 2INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: .29Y7 ,S' Akvv W 54k^l FARM TANK-YES❑ NO FV W 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY -4 A. OWNERS TANK ID# Q I B. MANUFACTURED BY: U t< -4 C. YEAR INSTALLED lqr7 s D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED, MPLETE ITEM D. A Fo 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM E C. Dn 1 UNLEADED ❑2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL �1 PRODUCT ❑4 GASAHOL [:] 5 JET FUEL ❑6 AVIATION GAS E]5 HAZARDOUS E] 80 EMPTY El 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&CAS.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEMrj/2SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER FPI 1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4STEEL CLADW/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL F-15 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8100%METHANOL COMPATIBLE FOP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ N OTHER C. INTERIOR F-11 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑ HENOLIC LINING LINING F-15 GLASS LINING ID UNLINED 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH IW%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ 1 POLYEIHLENE WRAP ❑2 TAR OR ASPHALT n INYLWRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE BUY 995 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A#1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 UNEDTRENCH A U 91 NONE A 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 A b6 CONCRETE A U 7 STEEL CLAD WERE A U 8 100%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. P S 1VISUAL CHECK S 2 INVENTORY RECONCILIATION P S 3VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED IMO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES ElNO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT, APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COmNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 17T la I D I / S Off' OD I / CURRENT LOCAL AGENCY FACILITY ID X APPROVED BY NAME PHONE#WITH AREA CODE i!W PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT MM I SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIBIwY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A tORRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY