BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

TANK TANACERMIT APPLICATION INFORNW&ON ?„ COMPLETE A SE TE FORM WITH THE FOLLOWING INFORMATI'FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7PERMANENTLY C ONE ITEM ❑ 2 INTERIM PERMIT ❑ l AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE B TANK R7L FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM- AT�� FARM TANK-YES❑ NO _7 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 10 A. OWNERS TANK ID N B. MANUFACTURED BY: C. YEAR INSTALLED /l ? 1 D TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. (y A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B C ❑ I UNLEADED EEI'2 LEADED ❑3 DIESEL N ❑ 3 CHEMICAL PRODUCT ❑ 1 OIL LaIrPRODUCT ❑ d 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 C.A.S.k C.A.S. X111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.8,C,8 D A. TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM El 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER La I STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS E]1 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ MATERIAL 5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RUBBER LINED El2 ALKYD LINING ❑ 3 EPDXY LINING ❑/PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑6 UNLINED 95 UNKNOWN E] IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL' [:]YES ❑ NO a99 OTHER i4"*' D. CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑/FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE �95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND. U IF UNDERGROUND.BOTH IF APPLICABLE A SYSTEM TYPE A67 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U < FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A JLj�6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A V 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. P S 1 VISUAL CHECK P 5 2 INVENTORY RECONCILIATION 3 VADOSE WELLS P S G ELECTRONIC MONITOR P S S GROUND WATER MONITORING WELLS W� P S 6 PRECISION TESTING P S 7 PRESSURE TESTING �91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I. ESTIMATED DATE AST USED(MO/YR) J2 ESTIMATED 0 ANTITY OF 3 WAS TA K FILLED WITH SUBST ANC. EI�AI TY O IN INERT ATJ:RIAL� ❑YES ❑ NO GALLONS THIS FORM NAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED t'+SIGNATURE 1 � i LOCAL AGENCY USE ONLY COUNTY M JURISDICTION N AGENCY01 FACILITY ID N TANK IO N CURRENT LOCAL AGENCY FACILITY 10 N APP WO BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N 8Y: FORM B(3-7.88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY --- •