BILLING 1985-1999 - Laserfiche WebLink

Home Browse Search

bl Al E OF CALIFOHN WATER RESOURCES CONTRA ONT BOARD FORM'B': UND GROUND STORAGE TANK PRMRAMQo TANK / TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT u S CHANGE OF INFORMATION ❑ 7 PERMANENTLY C�Q Tnuv - ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT % ❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: -�j ��, _ •>~ S% S�/� " 4, FApY TANK -YES ❑ NO ❑�� I. TANK DERCRIRTInN - varca.lrT - '^- A. OWNERS TANK IDN I B. MANUFACTURED BY: (J C. YEAR INSTALLED i G) ") D TANK CAPACITY IN GALLONS 1(f7r7� T � �/ - - . — ..- v, wlllrlc l E I TEM C. IF (A.1), IS NOT A. L.__f" MOTOR VEHICLE FUEL ❑ 2 PETROLEUM [LI, F-13 CHEMICAL PRODUCT 4 OIL PRODUCT ❑ 5 HAZARDOUS ❑ 60 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE D. IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF HAZARDOUS SUBSTANCE STORED & C.A.S. N TANK CANRTRnYrTlnu LARKED OMPLETE ITEM D. C. 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 7 METHANOL ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) C.A.S. p: A TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER B. TANK ❑ I STEEL/IRON❑ CONCRETE 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLAS$ REINFORCED PLASTIC MATERIAL[:D5 ❑ 9 BRONZE ❑ 6 POLYVINYLCHLORIDE ❑ 10 GALVANIZED STEEL ❑ 7 ALUMINUM ❑ 95 UNKNOWN ❑ B 10096 METHANOL COMPATIBLE FRP ❑ 99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD UNING ❑ 3 EPDXY LINING ❑ 4 PHENOUCUNING 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 TAR Ofl ASPHALT ❑ 3 VINYL WRAP ❑ INFORCED PLASTICPROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN IFIBERGLASS ❑ IV. PIPING INFORMATION CIRCLE A IF ABOVE GRnI Inn a IF ue A SYSTEM TYPE C. MATERIAL A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER 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 I STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE A U 91 NONE A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U S 100% METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY. OR S FnRsacnuneov . _. VI, - - --------- • •,,,•,. - Lc vc I cc I wN 5Y5TEM MUST BE CIRCLED. P S I VISUAL CHECK P S 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 S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 8 99 OTHER IN Fn O RM A Tlnu nu T. u.. .. -----------•- -•- •-,••... r�mm�ncnILT q LUStU IN PLACE 1. ESTIMATED DATE LAST USED IMO/YR) 2. ESTIMATED QUANTITY OF SUBSTANCE REMAINING IN GALLONS 3. WAS TANK FILLED WITH INERT MATERIAL? ❑ yE$ ❑ NO rwc • • ••... w+� lv wlwrLC I CU UIVUhH PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND C( APPLICANT'S NAME (PRINTED 6 SIGNATURE) DATE FN!`V I lee n COUNTY # JURISDICTION # t Ll L, CURRENT LOCAL AGENCY FACILITY ID APPROVED BY NAME M n. PERMIT NUMBER AGENCY # FACILITY ID M L, APPROVED BY NAME I- T`/--7 PERMIT CHECK# I PERMIT AMOUNT BURCHAgGE AMT. FEE CODE TANK ID k RRECT i, PHONE # WITH AREA CODE BY: - \ 1 "FORM B (6-29-88) THIS FORM MUST BE ACCOMPANIED BYA FACILITYISITE APPLICATION, FORM 'A', UNLESS A Cit"TIARENT FORMA' HAS BEEN FILED DATA PROCESSING COPY p