Laserfiche WebLink
STATE OF CALIFORNI.P WATER RESOURCES CONTRO' 'OARD <br /> FORM 'B': - UNDEftROUND STORAGE TANK PRO AAM <br /> TANK TANK PERMIT APPLICATION INFORMATIONo. <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> MARK ONLY ❑ 1 NEW PERMIT 0 3 RENEWAL PERMIT ZO <br /> ONE ITEM �5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED TANK <br /> 2 INTERIM PERMIT 0 4 AMENDED PERMIT E16 TEMPORARY TANK CLOSURECl - <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: p� L,I S_ANK REMOVED O <br /> S"i FARM TANK-TEED NO IV <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN <br /> SO SPECIFY � <br /> A. OWNERS TANK IDq N <br /> YEAR INSTALLED <br /> B. MANUFACTURED BY: <br /> C. (� . <br /> D. TANK CAPACITY IN GALLONS: <br /> II. TANK CONTENTSIF(A.1),IS MARKED,COMPLETE ITEM C.IF(A,1),IS NOT MARKED,COMPLETE ITEM D. <br /> EIFNOT <br /> MOTOR VEHICLE FUEL � 2 PETROLEUM g C <br /> 1 UNLEADED 2 LEADED 3 DIESEL <br /> CHEMICAL PRODUCT q OIL 1 PRODUCT 0 4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> HAZARDOUS 80 EMPTY Ej 95 UNKNOWN 2 WASTE 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> MOTOR VEHICLE FUEL,ENTER NAME OFOUS SUBSTANCE STORED 8.C.A.S.4 <br /> C.A.S.k: <br /> 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,0,C,A D <br /> [& TYPE OF 7SINGLEWALLED <br /> 0 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> STEM 0 4 SECONDARY CONTAINMENT �99 OTHER <br /> NK ❑ 2 STAINLESS STEEL 3FIBERGLASS Ej4STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> TERIAL0 6 POLYVINYLCHLORIDE 7 ALUMINUMB 100%MEIHANOL COMPATIBLE FRP <br /> 0 10 GALVANIZED STEEL 95 UNKNOWN E] 99 OTHER <br /> C. INTERIOR IRUBBER UNED 02 ALKYD LINING ❑ 3EPDXY LINING 4PHENOLICUNING <br /> LINING ❑ 5 GLASS UNING E]6 UNLINED <br /> pNKNOWN <br /> IS LINING MATERIAL COMPATIBLE WITH 10096 METHANOL? 0 YES [] NO E:4- OTHER <br /> D.CORROSION ❑ I POLYETHLENE WRAP 2 TARORASPHALT 0 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION E] 5 CATHODIC PROTECTION E]91 NONE5 UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A SYSTEM TYPE A U 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 U 5 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^6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 10096 METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZEDSTEEL I p M5 UNKNOWN A U 99 OTHER <br /> V EAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> JP S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P 8 99 OTHER <br /> VI. 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? EYES [�] 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 B SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION R AGENCY N FACILITY ID R TANK ID R <br /> m 101o I l I ° I C0 <br /> CURRENT LOCAL ADEN FACILITVOD M APPROV�B'[NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER LL PERMIT APPROVAL DATE C PERMIT EXPIRATION DATE <br /> CHECK M PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT• BY: <br /> FORM B(6-29-BB) THIS FORM MUST BE ACCOMPANIL BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESSTMRENr FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />