BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNI40 WATER RESOURCES CONTRO OARD FORM 'B': UNDERGROUND STORAGE TANK PROI AM TANK TANK PERMIT APPLICATION INFORMATION CO LETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _ Z MARK ONLY 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TAN ) ONE ITEM 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED d / FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO W I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY CTI cn A. OWNERS TA NK ID B. MANUFACTURED BY: u -4 C. YEAR INSTALLED �� D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM e. C. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL F-] 3 CHEMICAL ET FUEL ION GAS ❑ 5 HAZARDOUS PRODUCT 800EMPTY ❑ 95 UNKNOWN/ ❑ 1 WASTE CT ❑7 METHANOL ❑99J OTHER(DESCRIBE❑IN ITEM DT BELOW) O IF NOT AZAARDOUS SUBSTANCE STORED&C.A S.#CLE FUEL,ENTER NAME OF GU(( � O C.A.S.#: 40-5 III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF 1 DOUBLEWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑ 2 SINGLEWALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC S.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR F-11 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING ❑6 UNUNED UNKNOWN ❑ ISLINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 PO YETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3 VINYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION 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 ;n GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED 411-u-,> DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON AU 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U 7 STEELCLADW/FRP A U 8 1 OD%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 FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3VADOSE WELLS/P E 4ELECTRONIC ONITOR P 8 5 GROUND WATER MONITORING WELLS IUA' P 8 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE �P�B 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑`SES F] 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY IDM TANK ID;# 3 ` � 01 10063 CURRENT LOCAL AGENCY FACILITY ID# APP V D BY ME PHONE#WITH AREA CODE coo III 1 PERMIT NUMBER PERMIT APPROVAL TE PERMIT EXPI TION ATIN l a '3 (oj CHECK M PERMIT AMOUNT SURCHARGE AM FEE CODE p CEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCO IED BY A FACILITY/SITE APPLICATION, FORM `A',UN A CURRENT FORM W MAS BEEN FILED DATA PROCESSING COPY