BILLING - Laserfiche WebLink

Home Browse Search

WATER RESOURCES CONTRO ARD STATE OF CALIFORNIq� FORM 'B': UNDERGROUND STORAGE TANK PROGRAM 3 TANK TANK PERMIT APPLICATION INFORMATION ry,. �• CO LETE A SEPARATE!q#M WITH THE FOLLOWING INFORMATION FOR EACH TANK. 1 NEW PERMIT 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑7 PERMANENTLEl'I ANK MARK ONLY 6 TEMPORARY TANK CLOSURE ❑6 TANK REMOVEP� , ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT FARM TANK-YES❑ NO FACILITY/SITE NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SBE MFY ANUFACTURED BY: A. OWNERS TANK ID# A D. TANK CAPACITY IN GALLONS: 0 ti o d G YEAR INSTALLED I1. TANK ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A 1),IS NOT MARKED,CUNLFI EOE IT❑EM 2 LEADED ❑3 DIESEL e. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS 1 PRODUCT 3 CHEMICAL PRODUCT ❑4 OIL 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) ❑5 HAZARDOUS ❑ SO EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑ ❑ O. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.#: HAZARDOUS SUBSTANCE STORED&C.A.S.# Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D r ❑3 SINGLE WALL ED WITH EXIENOR LINER ❑95 UNKNOWN A.TYPE OF ,GUS WALLED ❑99 OTHER SYSTEM INGLEWALLED ❑4 SECONDARY CONTAINMEM TEEL/IRON ❑2 SIAINLESSSTEEL ❑3 FIBERGLASS ❑4 STEEL CLAD WNIlBCEORGIASS REINFORCED PLASTIC FATIGUE 8.TANK INUM CONCfiEIE ❑69PGALVANIZED STEELOLYVINYL S ❑ 95AUNKNOWN LUM ❑ N OTHER HS% '��FRP MUM MATERIAL ❑9 BRONZE ❑ ❑ ❑1 RUBBER LINED ❑2 ALKYOUNING ❑3 EPDXY LINING ❑,.,4 PPHENOLIC LINING C. INTERIORASS NING ❑6 UNLINED (�I'95JdNKNOWN LINING ❑5 GIVING MATE rn�,T( ❑ IS LINING MATERIAL COMPATIBLE W'TH 100%MEOiANOL? ❑YES ❑NO OTNEA D. CORROSION ❑1 POLYEO4ENE WRAP ❑2 TAR OR ASPHALT ❑3 LWPAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A WAS VEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE 95 UNKNOWN A U 99 OTHER tTlR TYPE A U 1 SUCTIONA U 2 PRESSURE A U3GRU1NONE A 95 UNKNOWN A U 99 OTHER UCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONEA U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE AL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 10U%METMANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 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. �-=��ESSUS NTORY RECONCILIATION P S 3 VADOSEWELLS P8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLP E TESTING P B 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3.WAS TANKFILLEDWITH 2. ESTIMATED QUANTITY OF INERT MATERIAL? E]YES El NO 1.ESTIMATED DATE LAST USED(MO/YR) SUBSTANCE REMAINING IN GALLONS OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. THIS FORM HAS BEEN COMPLETED UNDER PENALTY APPLICANT'S NAME(PRINTED&SIGNATURE) LOCAL AGENCY USE ONLY FACILITY ID# COUNTY# TANK ID## JURISDICTION AGE 7NE# V V l APPROVED BY NAME PHOITN AREA EA CODE CURRENT LOCAL AGENCY FACILITY IDA � (/ [,/✓! APPROVAL DATE PERMIT EXPIRATION DATE PERMIT NUMBER CHECKk PERMIT AMOUNT SURCHARGE AMT. FEE CODE ECEIPTM BY: � FORM 0(6-29-66) THIS FORM MUST BE ACCOMPANIED BY A FACILITYDATA PROCION, run COPA',UNLESS A CURRENT FORMA' HAS BEEN FILED