BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFOFSA WATER RESOURCES COAbL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK PERMIT APPLICATION INFORMATION TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT Q'S CHANGE OF INFORMATION Ell PERMANENTLY CLOSED TANK, t0 ONE ITEM ❑ 2INTERIM PERMIT ❑A AMENDED PERMIT E] 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED FACILITY/BITE NAME WHERE TANK IS INSTALLED: -J/_ p FARM TANK-YES❑ NO N J� 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-80 SPECIFY Ia A. OWNERS TANK IDN B. MANUFACTURED BY: C.YEAR INSTALLED q ID. TANK CAPACITY IN GALLONS: /00(D II. TANK CONTENTS IF WI),18 MARKED,COMPLETE ITEM C.IF(A.1),IS NO MARKED,COMPLETE ITEM D. A. I MOTOR VEHICLE FUEL ❑ 2 PETROLEUM 8. C. ❑ I UNLEADED LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ /OIL PRODUCT ❑ / GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL E] 99 OTHER(DESCRIBE IN ITEM 0,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 6 C.A.S.N C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK Al,S.C,A D A.TYPE OF ❑T� "U WALLED ❑ 3 SINGLE WALLED WITH DRERIOR LINER ❑ 95 UNKNOWN SYSTEM E9 2 SI LIED ❑A SECONDARY CONTAINMENT ❑99 OTHER SFEELIIRON ❑ 2 SIAINLESS STEEL ❑ 3 FIBERGLASS ❑ 1 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑8 POLYVINYLCHLORIDE ❑I ALUMINUM ❑ B 1 O METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ IO GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ I RUBBER LINED ❑2 ALKYDLINING ❑ 3 EPDXY LINING ❑ I PHENOLIC LINING C.INTERIOR LINING ❑5 CUSS LINING a8 UNLINED ❑ 95 UNKNOWN ❑B LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER F SION ❑ I POLYER%ENEWRAP ❑2 TARORASPHALT ❑ 3�WRAP ❑ I FIBERGLASS REINFORCED PLASTIC CTION ❑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 U l SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 5 UNKNOWN,�A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE LED A U 2 DOUBLEWALLED A U 3 LINED TRENCH A U 91 NONE A 95 UNKNOWN 'A U 99 OTHER A. U I STEE�RON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U < FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 10096 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 6 1 VISUAL CHECK 11 6 2 INVENTORY RECONCILIATION P 6 3 VAOOSE WELLS P 6 0 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 6 8 PRECISION TESTING P 6 7 PRESSURE TESTING P 6 91 NONE P 6 UNKNOWN ) P 8 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 SUBSTANCE REMAINING IN pALLONB INEflT MATERIAL? ❑VES ❑ 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTYIN JURISDICTION M AGENCY N FACILITY ID N TANK ID N �r 7 CURRENT LOCAL AGENCY FACILITY ID N APPROVED B --- Y NAME PHONE N WITH AREA CODE & /�J/ PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECKIP PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N L� 7 FORM B(829-68) THIS FORM MUST BE ACCOMPANIED BY A FACILMISITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA OR(1C PBCIMY- f`DOV