BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORkV WATER RESOURCES CONL BOARD FORM B': UN P RGROUND STORAGE TANK GRAM ` TANK - TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 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 ❑8 TANK REMOVED �s FACILITY/SITE NAME WHERE TANK IS INSTALLED: 07Oej�S FARM TANK-YES❑ 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIF OD A. OWNERS TANK ID# B. MANUFACTUREDBY: 'h► C. YEAR INSTALL - D. TANK CAPACITY IN GALLONS: II. TANK C BENTS < IFMA T>,IS MARKED,COMPLETE ITEM C.IF(A.7),IS NOT MARKED,COMPLETE ITEM D. A_ 1 MOTOR VEHICLE FUEL F-1 DE jRtT90LEUM C. ❑ 1 UNLEAD 2 LEADED ❑ 3 DIESEL F--] B 3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# }� CAS #. III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ I DOUBLEWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINED UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEEUIRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 AW UM ❑ 8 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL M'<UNKNOWN ❑ 99 OTHER C. INTERIOR F--] I RUBBER LINED El ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PH LIC LINING LINING ❑5 GLASS LINING ❑ 6 UNLINED 95 UNKNOWN ❑ ISLINING MATERIAL COMPATIBLE WITH 160%MEIHANOL? ❑ YES ❑ NOOTHER /ice✓-'^"A�/ D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VI AAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 5 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 A U 3 GRAVITY A U 91 NONE A UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE U 5 UNKNOWN A U 99 OTHER A U 1STEELARON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 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 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 9 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 1VISUALCHECK P S 2 INVENTORY RECONCILIATION P S 3VADOSEWELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURETESTING S 1 NONE P S 95 UNKNOWN P S 99 OTHER V1. 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 GALLONS INERT MATERIAL' 1:1YES ElNO 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 COUNTY# JURISDICTION# AGENCY# FA CI # TANK ID# = E= - a CURRENT LOCAL AGENCY FACILITY ID N - APPROVED BY NAM PHONE N WITH AREA CODE rJ(lXi2.6 «� PERMIT NUMBER PERMIT APPROVAL DATE RMITYPIRATION D CHECKN 7PERMITAMOUNT URCHARGE AMT. FEE CODE CEIPTN BY: FORM B(6-29-8e) THIS FORM MUST BE ACCOMPANIED A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A C RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY