BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNJJ WATER RESOURCES CONTR.BOARD FORM 'B': UND GROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK TAH✓ `'� ONE ITEM ❑2INTERIM PERMIT 4 AMENDEDPERMIT 6 TEMPORARY TANK CLOSURE ❑ ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: "T cI/� Q �' FARM TANK-YES❑ NO I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLED lc-- D. TANK CAPACITY IN GALLONS: �sO II. TANK CPNfENTS 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. ❑ 1 UNLEADED E] 2 LEADED 3 DIESEL ❑3 CHEMICALPRODUCT ❑ 4 OIL u11PPRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN E] 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.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A TYPE OF ❑1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER 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.TANK ❑ POLYVINYLCHLORIDE MATERIAL 5 CONCRETE fi❑ ❑7 NUM ❑8100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑10 GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER C.INTERIOR E]1 RUBBER UNED 2 ALKYD LINING 3 EPDXYLINING ❑4 P LIC LINING ❑ ❑ LINING ❑5 GLASS LINING ❑6 UNLINED 95 UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH IN%METHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHALT 3 VI P [:]4 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 A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U NKNO N 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 WN 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 A U 6C A U 7 STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 95 UNKN N I 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 8 ;=ION CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 EL IC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONEP B 4k UNKNOW P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LASTUSED(MO/YR) 2. ESTIMATEDOUANTITY OF SUBSTANCE REMAINING IN 3 WAS TANK FILLED WITH OALLONB INERT MATERIAL? ❑yE$ ❑ 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 B SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION# AGENCY N ID R TANK ID# 3 � � 9 � CURREN CAL EN YFACILITYI N APPROVED BY NAME V C 1 PHONE N WITH AREA CODE PERM ER PERMITAPPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCH GE AMT. FEE CODE RECEIPT NBY: F V V\O FORM B(8-29-BB) THIS FORM MUST BE ACCOMPANIED BY A FITC 1TY/SITE APPLICATION, FORM 'A',UNLESS A CURRE ORM-A, HAS BEEN FILED �\ DATA PROCESSING COPY