BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORh* WATER RESOURCES CONT BOARD FORM 'B': UNDERGROUND STORAGE TANK PR RAM COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH YANK TANK TANK PERMIT APPLICATION INFORMATION �. MARK ONLY ❑ 1 NEW PERMIT P_ .V 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ONE ITEM ❑2 INTERIM PERMIT �0�7 ERMANENTLY CLOSED TANK ❑4 AMENDED PERMIT6 TEMPORARY TANK CLOSUREFACILITY/SITE NAME WHERE TANK IS INSTALLED: ANK REMOVED r to rtj 1. TANK DESCRIPTION COMNK-YES NO FARM TA ❑PLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK YO# B. MANUFACTURED BY, C. YEAR INSTALLED 11. TANK ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A,),IS NOT MARKED,COMPLETE ITEM D10 D©� A. 1 MOTOR VEHICLE FULL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED ❑"2 LEADED ❑ 3 CHEMICAL PRODUCT ❑ 4 OL �DIESEL ❑ 8Q EMPTY 95 UNKNOWN PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS 5 HAZARDOUS ❑ ❑ D, IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF ❑2 WASTE ❑ 7 METHANOL ❑ 9g OTHER(DESCRIBE IN ITEM D,BELOW) HAZARDOUS SUBSTANCE STORED&C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,8,C,It D CA.S.#: A.TYPE OF ❑ I DOUBLE WALLFD ❑3 SINGLE WALLEO WITH EXTERIOR LINER SYSTEM P 12 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑95 UNKNOWN ❑99 OTHER I STEELIIRON ❑2 STAINLESS STEEL B. TANK ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE7 ALUMINUM ❑ 9 BRONZE ❑ ❑8 100°5 METHANOL COMPATIBLE FRP ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RUBBER L1NED ❑ 2 ALKYD LINING LINING ❑5 GLASS LINING ❑3 EPDXY LINING ❑ 4 PHENOLIC LINING ❑ 6 UNLINED ❑95 UNKNOWN ❑ IS LINING MATER IAL COMPATIBLE WITH T00%METHANOL? ❑YES ❑ NO 49 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ PROTECTION 9 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC ❑ 5 CATHODIC PROTECTION ❑ 91 NONE L,:j95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMA N CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A sucnoN A U 2 PRESSURE A U 3 GRAVITY B. CONSTRUCTION U SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U i STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 9 GALVANIZED STEEL A 5 UNKNOWN A U 9 A U 8 100%METHANOL COMPATIBLE FRP \(✓� 9 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION 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 P 'Al NONE P S 95 UNKNOWN VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE P s 99 OTHER 1 ESTIMATEI DATE LAST USED(MOlYR} 2. ESTIMATE(} UANTITY OF SUBST C _ 1AINING IN 3, WAS TAN F LLED WITH jq GALLONS INE IAL? ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLE GE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY ID# 1:� AGENCY# TANK ID# r . CURRENTLOC pL AGENCY FACILITY 1110 APPA VED BYNA PHONE 0 WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE P RM EXPIRATION DATE CHECK k PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM a(6-29-88) THIS FORM MUST RE ACCOMPANIEUTY A FACILITY/SITE APPLICATION, I`ORM 'A',UNlE$$A RENT FORMA' NAS BEEN FILED DATA PROCESSING COPY ��-