BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORN► - WATER RESOURCES CONTRA BOARD FORM 'B': UNDMGROUND STORAGE TANK PROZaRAM TANK TANK PERMIT APPLICATION INFORMATION "K\o COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE �ANK REMOVED N FACILITY/SITE NAME WHERE TANK IS INSTALLED: aAAZAa- FARM TANK .A -YES❑ NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY ' r1 05159'o QI A. OWNERS TANK ID# ''Z/ B. MANUFACTURED BY. 1--J C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. El 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM EFC. ❑ 1 UNLEADED L'J 2 LEADED ❑ 3 DIESEL F-13 CHEMICAL PRODUCT ❑4 OIL PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 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 CA&# C.A.S.4,4/ A III. TANK CONSTRUCTION MARK ONE ITE ONLY IN BOX A,B,C,&D A.TYPE OF UBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM fpl 2 SINGLEWALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 ;EEL/IRON 2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE F-]6 POLYVINYLCHLORIDE F-] 7 ALUMINUM E:]B IOD%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL [:] 95 UNKNOWN ❑99 OTHER ❑ C. INTERIOR I RUBBER LINED ❑ 2 ALKYD LINING F-13 EPDXY LINING E] 4 PHENOLIC LINING LINING ❑5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ I POLYETHLENE WRAP ❑ 2 TARORASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION91 NONE ❑95 UNKNOWN E] 99 OTHER IV. PIPING INFORMAN 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 U 95 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 A U 95 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 AALUMINUM A U 6 CONCRETE A U ] STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A(p 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. NOejt P 8 1VISUAL CHECK P S 2 INVENTORY RECONCILIATION VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P S ] PRESSURE TESTING P 1 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. ESTIMATE QUANTITY OF 3.WAS TAN FILLED WITH SUBS A EMAINING IN IV L? ❑YES ❑ NO GALLONS n/ THIS FORM HA BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# !Sv 1 Z o 3 UO lo CU RENT L9('.AL AGENCY FACILITY ID# ApPROV-T BY NAME / / PHONE M WITH AREA CODE PERMIT NUMBER `/ PERMIT APPROVAL DATE '�('(jI�'PERM1 E%PI ATICO�Nu/DATE 1 CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORMB(6-29-66) THIS FORM MUST BE ACCOMPANIE YAFACILITY/SITE APPLICATION, FORM 'A',UNLESS A t;URRENT FORMA HASBEENFILED DATA PROCESSING COPY