BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIO WATER RESOURCES CONTROARD -�. FORM 'B': UNDERGROUND STORAGE TANK PRO RAM TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWIN ORMATION FOR EACH TANK. Z TANK 1 NEW PERMIT ❑ 3 RENEWAL PER 5 CHANGE OF INFORMATIONID 7 ERMANENTLYCLO 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED MARK ONLY F-1D ONE ITEM E] 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ dv �- FARMTANK-YES[:] NO W FACILITY/SITE NAME WHERE TANK IS INSTALLED: r' Q I � I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY � B. MANUFACTURED 8Y: A. OWNERS TANK ID p OO D. TANK CAPACITY IN GALLONS: C.YEAR INSTALLED III II. TANKg2NTENTS IF(A•1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMEPAL ED ITEM D. LEADED 3 DIESEL A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM F-13 CHEMICAL PRODUCT ❑4 OIL KE:] 2 RODUCT ❑4 GASOHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ SO EMPTY ❑95 UNKNOWN ASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.N: HAZARDOUS SUBSTANCE STORED&C.A.S.p 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 111GUBLEWALLED F-13 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 NGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC S.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE 7 ALUMINUM ❑ 8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBERUNED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING n 4,QHEN000 LINING C. INTERIOR ❑5 GLASSUNING ❑6 UNUNED Ell 95 KNOWN LINING ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO 99 OTHER G. CORROSION ❑ 1 POLYEIHLENE WRAP ❑2 TARORASPHALT ❑ INYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION El 91 NONE UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 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 1 SINGLEWALLED A U 2 DOUBLE WALLED A U 3 LINEDTRENCH A U 91 NONE U 5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U 7 STEELCLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 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. 11 / S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 3 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS IUj� P 6 PRECISION TESTING P S ] PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO GALLONS 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 COUNTY p JURISDICTION p AGENCY p FACILITY ID p TANK ID p ooa9 K FoOo CURRENT LOCAL AGENCY FACILITY ID p APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER !/VG57 ePERMIT APPROVAL DATE PERMIT EXPIRATION DATE -Is '�� �(\\ CHECK M PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY./� \\� M B(6-29-9B) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM'A',UNLESS p CURRENT FORMA HAS BEEN FILED �l DATA PROCESSING COPY