BILLING 1985-1999 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNM WATER RESOURCES CONTPOBOARD FORM B': UND RGROUND STORAGE TANK PR GRAM TANK TANK PERMIT APPLICATION INFORMATIONe ° COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATInN FnD FArY rAMY MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 P MANENTLY CLOSED T ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE apeTANK REMOVED d FACILITY/SITE NAME WHERE TANK IS INSTALLED: S FARM TANK - YES ❑ NO � umr'C I CALL I 1 tMS -IF UNKNOWN — Rn SDFr.cY A. OWNERS TANK IDN Q , B MANUFACTURED BY C. YEAR INSTALLED D TANK CAPACITY IN GALLONS. :012 � ed D TANK CONTENTS IF (All IRMwaKFn rn.........e. III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A. B- C- A D A. TYPE OF ❑ 1 DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOfl LINER A. IR41 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. SYSTEM C.❑ 1 UNLEADED ❑ 2 LEADED 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL 1 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 GAS # C.A.S. #: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A. B- C- A D A. TYPE OF ❑ 1 DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOfl LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALLED 4 SECONDARY CONTAINMENT ❑ 99 OTHER B. TANK ❑ I STEEL/IRON STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLADWIFIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ fi LYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 106% METHANOL COMPATIBLE FRP A ❑ 9 BRONZE ❑ 10 LVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKY LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑ 6 UNLINE ❑ 95 UNKNOWN ❑ 15 LINING MATERIAL COMPATIBLE WITH 100%MET NOL? ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑ 2 TAR OR ASPHA ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 95 UNKNOWN B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WP A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS, 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE 6100% METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN IF UNDERGROUND, BOTH IF APPLICABLE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER 3L A U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE A U 91 NONE A U 7STEEL CLAD W/FRP A U 6100% METHANOL COMPATIBLE FRP U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY, OR S FOR ECONDARY, A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELL P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLA 1. ESTIMATED DATE LAST USED (MO/YR) 2. ESTIMATED QUANTITY OF 3, WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE ST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME (PRINTED S SIGNATURE) I DATE .VL:AL AGENCY USE ONLY COUNTY # JURISDICTION # AGENCY # FACILITY ID # 60I7FT TANK 10 # 0-T-( CURRENT LOCAL AGENCY ID APPROVED BY NA)/L- Z' / LL/ N /l � PHONE # WITH AREA CODE PERMIT NUMBER CHECK# I PERMITAMOUNT PERMIT APPROVAL DATE AMT. I FEE CODE DATE BY: FORM B (6-29-88) THIS FORM MUST BE ACCOMPANIEIIT/ A FACILITY/SITE APPLICATION, FORM 'A', UNLESS ArRREWT FORMA' HAS BEEN FILED DATA PROCESSING COPY Z 10 (Ai N 00 V nN2�