BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFOFW WATER RESOURCES COAL BOARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM Qp TANK > • TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑O RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 1 AMENDEOPERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED 9D- FACILITY/SITE NAME WHERE TANK IS INSTALLED: i5_(' FARM TANK•YES❑ NO ❑ I. TANK DESCRIPTION COMPLETE ALL ITEMS•IF UNKNOWN—SO SPECIFY A OWNERS TANK IDE B. MANUFACTURED BY: L.((�-- C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: gLx0u j II. TANK 9ONTENTS 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. ❑ I UNLEADED LEADED ❑ O DIESEL ❑S CHEMICAL PRODUCT ❑ 1 OIL I PRODUCT ❑ GASAHOL ❑ 5 JET FUEL ❑ B AVIATION GAS ❑ 5 HAZARDOUS ❑ SO EMPTY ❑95 UNKNOWN 021 HANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF HAZARDOUS SUBSTANCE STORED A C.A.S.I CA.S.1: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOT(A,B.C.A D A TYPE OF ❑ I WALLID ❑9 SINGLE WAILED WITH EXTERIOR LINEA ❑95 UIKNOWN SYSTEM 2 SI WALLED ❑/SECDHDARY CONTAINMENT ❑99 OTHER STEEURON ❑2 STAINLESSSTEEL ❑7 FIBERGLASS ❑ 1 STERDLIDW/FIBERGLASSREINFONCEDRASTIC 9.TANK ❑ 5 MUIETE ❑1 POLYVIm CFEORIOE ❑7 ALUMINUM 111W%METIMNOLCOMPATIBLEFRP MATERIAL 9 B(IONZE ❑ 10 GALVANIZED STEEL E]95 UNKNOWN ❑ 99 OTHER G INTERIOR 1:11 FUBBERUNLD ❑2 WING ❑G EPDXY LINING E]/PHENOLX:UNINB LINING ❑5 MUSS LBINK9 LNLINED ❑95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH IIWI%METHANOL7 ❑YES ❑NO ❑ 99 OTHER 0. CORROSION ❑ I POLYRILFNE WRAP ❑ 2 T ASPHALT ❑9 VINYL WRAP ❑ 1 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 1 A U R PRESSURE A U B GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U I LE W A U 2 DOUBLE WALLED A U B LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER 4 A USTEEL/IRO � A U 2 STAINLESS STEEL A U 9 POLYVINYL CHLORIDE(PVC) A U I FIBERGLASSPIPE A U 9t NONE C.MATERIAL A U S ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B IBO%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL A U 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 B 1 VISUALCHECK P 5 2 INVENTOR/RECONCILIATION P 2 9 VADOSE WELLS P / 1 ELECTRONIC MONITOR P E 5 GROUND WATER MONITORING WELLS P E. 5 PRECISION TESTING P E 1 PRESSURE TESTING P '9fNONE P I 95 UNKNOWN P E 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I. ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED QUANTITY OF 7.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAl2 GALLONS E)YES ❑ 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 L SIGNATURE) DATE LOCAL AGENCY USE ONLY V COUNTY 1 JURISDICTION 0AGENCY 1 FACILITY ID E TANK ID = = a % S C77�3 C) o b / CURRENT LOCAL AGENCY FACILITY ID 1 APPROVED BY NAME PHONE 1 WITH AREA CODE G 17AICI S / 7YI PERMITHUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE AISL CHECKI PERMIT AMOUNT SURCHARGE AMT. FEE CODE ECEIPTA aY:� F OIIM RIS99-M1 THIS FORM MINT RF AOCOMDAMICR RY 1 CAPI1"ltltt led IP-1 ...... ...............