BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNM WATER RESOURCES CONTP BOARD FORM `B': UND GROUND STORAGE TANK PR RAM " TANK TANK PERMIT APPLICATION INFORMATION m,ro COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE �Prs TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED:Z psy S-sm., C�. FARM TANK-YES❑ NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY IC) A. OWNERS TANK ID# Q I 1 B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: C-6 O II. TANK CONTENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. F A ❑33 CHEMICAL VEHICLE RODUCT ❑ OL [Zll MOTOR L ❑ 4 PETROLEUM FB.TS; C. ❑ 1 UNLEADED 2 LEADED E] 3 DIESEL ET,"PRODUCT aRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑ BO EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAMEOF , l HAZARDOUS SUBSTANCE STORED&C.A.S.# N e;I6 G.A.S.#: AJ :III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ I DOUBLEWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM D/2SINGLEWAU.00 ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER STEELARON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM B 100%METHANOL COMPATIBLE FRP MATERIAL 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ W OTHER ❑ I RUBBER LINED n 2 aIXYD LINING F-13 EPDXY LINING ❑/PHENOLIC LINING C. INTERIOR IrQ>,/ E:]LINING ❑5 GLASS LINING 8 UNLINED 95 UNKNOWN ❑ ISUNING MATERIAL COMPATIBLEWITH 100%METHANOL? YES ❑NO 99 OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑2 T RORASPHALT ❑3 VINYLWRAP ❑4 RBERGLASS 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 071 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A Ull STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL A U 95 UNKNOWN A U 99 OTHER 1 V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. CIA P 5 1 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 19 S 91 NONEP 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH N /A SUBSTANCE REMAINING IN A GALLONS INERT MATERIAL?A) /,Q]YES D 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 ID# TANK ID# O I d -z-1 7 I b I I D 1 6 0 1 CURRENT LOCALAGENCY FACILITY IDM APPR VED YNAM PHONE#WITH AREA CODE S Q$ •1 P MI NUMBER - PERMIT APPROVAL DATE PERMIT EXPIRATION DATE `\\w-j\ CMECKM PERMIT AMOUNT SURCHARGE AMT. FEE CODE RE SURCHARGE BY: FORM B(3-7-68) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS 'RRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY