BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIP WATER RESOURCES CONTRO' -'OARD FORM 'B': UNDEIrGROUND STORAGE TANK PROMAM TANK TANK PERMIT APPLICATION INFORMATION m COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. -_ Z •o. 1 O MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK \TAqNK ONE ITEM F--] 2 INTERIM PERMIT F-14 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE TANK REMOVED V FACILITY/SITE NAME WHERE TANK IS INSTALLED: Q In ClU -j yiv Q, FARM TANK-YES❑ NO j► I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY C0 A. OWNERS TANK IDN S 2 Q C, 1 B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 1 V 6 II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. I�EADED ❑ 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT E] 4 OIL PRODUCT ❑ 4 GASAHOL ❑5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ BO 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 8 C.A.S.9 C.A.S.N: 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 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEELHRON ❑ 2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC 8.TANK ❑5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 1 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑ 99 OTHER F--] 1 RUBBER LINED ❑ 2 ALKYD LINING F--] 3 EPDXY LINING E] 4 PHENOLIC LINING C.LINING R ❑ 5 GLASS LINING ❑ 6 UNUNED KNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO OTHER uu'� D.CORROSION ❑ 1 POLYETHLENEWRAP 2 TAR OR ASPHALT ❑ 3 VINYLWRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 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 U 9 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE AC U 9 UNKNOWN A U W 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 U 6 CONCRETE A U 7 STEEL CLAD W/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. PI 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P B I PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR 2. ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES [_-] NO 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 R JURISDICTION M /AGENCY# FACILITY ID# TANK ID N CURRENT LOCAL AGENCY FACILITY 10 APPROVED IT NAM PHONE k WITH AREA CODE PE7tb12 la 511 id erg PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCNARGE AMT. FEE CODE RECEIPT• BY: FORM S B-29-w) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A RENT FORM W HAS BEEN FILED DATA PROCESSING COPY -