BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNO WATER RESOURCES CONTROOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATIONm ' COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. o MARK ONLY El NEW PERMIT ❑ 3 RENEWAL PERMIT E215 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED To I ONE ITEM F__] 2 INTERIM PERMIT F__] 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE TANK REMOVED !f FACILITY/SITE NAME WHERE TANK IS INSTALLED: r. FARM TANK-YES NO ❑ CTl rJ I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY W A. OWNERS TANK IDA m I B. MANUFACTURED BY: I--► C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK C NTENTS 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 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&C.A.S.# C A.S.#: A Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BO A,B,C,&D A.TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER 2/%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 ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE WMINUM El8 10096 METHANOL COMPATIBLE FRP E]MATERIAL //� 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING [:]F95 LIC LINING C. INTERIOR LINING ❑ 5 GLASSUNING ❑6 UNLINED OWN IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO R��"•- D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TARORASPHALT Li LWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION E] 5 CATHODIC PROTECTION [:]91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IFAPPLICABLE A.SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A 5 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINEDTRENCH A U 91 NONE A U 5 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 A LI')$CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A /UY/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 I VISUALCHECK P S 2 INVENTORY RECONCILIATION P 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS /)0 P S 6 PRECISION TESTING P S 7 PRESSURETESTING P 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE L ESTIM ED DATE LAST USED(MO/YR) 2. ESTI ATED QUANTITY OF 3, WA TANK FILLED WITH U NCE REMAINING IN GALLONS MATERIAL? E]YES E] NO T IS 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 COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# D 1 v I ya oll CURRENT LOCAL AGENCY FACILITY ID# APPR VED BY N PHONE#WITH AREA CODE .>� lAV4 7 PERMIT NUMBER PERMIT APPROVAL DATE P RMIT tXPIRAIrION DATE CHECK# PERMITAMOUNTSURCHARGE AMT. FEE CODE RECEIPT# BY: FORM 8(6-29-88) THIS FORM MUST BE ACCOMPANIEDWA FACILITY/SITE APPLICATION, FORM 'A',UNLESS A MIDENT FORM W HAS BEEN FILED DATA PROCESSING COPY