BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORN" " WATER RESOURCES CONTRA BOARD FORM `B': UNDtfiGROUND STORAGE TANK PRMRAM m o= y TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT f+, o..' I�+ ❑ ❑ 5 CHANGE OFINFORMATION ❑ 7 PERMANENTLY CLOSED`TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 4�TMNK REMOVED j FACILITY/SITE NAME WHERE TANK IS INSTALLED: SQ O FARM TANK-YES El NO ,\ I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY N A. OWNERS TANK 10# B. MANUFACTURED BY: Q O 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. 0 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑3 CHEMICAL PRODUCT ❑4 OIL ,�T�RODUCT ❑ 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&C.A.S.# C.A.S.#' j 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B.C,&D A.TYPE OF ❑ 1 DOUBLEWALLED ❑ 3 SINGLE WALED WITH EXTERIOR LINER 4w 95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANERML ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE F-] 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL f f 95 UNKNOWN ❑ 99 OTHER C. INTERIOR F--] 1 RUBBER UNED ❑ 2 ALKYD LINING E-13 EPDXY LINING E:] 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING F-1 6 UNLINED UNKNOWN � I' ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES F] NO ❑-99 OTHER IA K-. D. CORROSION ❑ I POLYETHLENEWRAP ❑2 TAOORASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE �-9SONKNOWN ❑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 5 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 UNKNOWN A U 99 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 AU 6 CONCRETE A U 7 STEEL CLAD WEEP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 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. P S 1 VISUAL CHECK P 5 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 3 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3, WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL'S ❑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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY C'O)U�N`T-Y�I# JURISDICTION# AGENCY N FACILITY ID# TANK ID R L+IJ�J CURRENT LOCAL AAGENCY FAILITY IDC # APPROVED B NAM '44 PHONE#WITH AREA CODE 1 1 �� PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE \ \ CHECK* PERMIT AMOUNT SURCHARGEAMT. FEE CODE RECEIPT# BY: \U1 FORM B(s-zs-se) THIS FORM MUST BE ACCOMPANI A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A RENT FORM W HAS BEEN FILED DATA PROCESSING COPY