REMOVAL_1990 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORN10 WATER RESOURCES CONTRI&OARD FORM B . UNDERGROUND STORAGE TANK PRRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT F-13 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE FACILITY/SITE NAME WHERE TANK IS INSTALLED: Q , 1. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY A. OWNERS TANK ID #Lf B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS ❑ 7 PE$MANENTLY CLOSED TAN TANK REMOVED /) FARM TANK - YES ❑ NO LL 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 B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL ❑ I PRODUCT ❑ 4 GASAHOL ❑ 5 UET 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 NAMF(}F CAS #: HAZARDOUS SUBSTANCE STORED & C.A.S. it Ill. TANK CONSTRUCTION MARKONEITIM,ONLY IN BOX A, B, C, & D A. TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE LLED WITH EXTERIOR LINER SYSTEM ❑ 2 SINGLE WALLED ❑ 4 SECONDA ONTAINMENT PHONE k WITH AREA CODE ❑ 1 STEEL/IRON ❑ 2 STAINLESS STE ❑ 3 FIBERGLASS B. TANK ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORI ❑ 7 ALUMINUM MATERIAL I� y BRONZE L❑� ❑ ip GALVANIZED STEEL ❑ 95 UNKNOWN BY: I RUBBER LINED ❑ 2 ALKYD LINING 3 EPDXY LINING C. INTERIOR LINING ❑ 5 GLASS LINING ❑ 6 UNLINED `A' HAS BEEN FILED ❑ IS LINING MATERIAL COMPATIBLE WITH10p%METHANOL? ❑ Y ❑ NO D. CORROSION ❑ I POLYETHLENEWRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYL RAP PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOIM ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 4 STEEL CLADW/FIBERGLASS REINFORCED PLASTIC ❑ B 100% METHANOL COMPATIBLE FRP ❑ 99 OTHER ❑ 4 PHENOLIC LINING ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 4 FIBERGLASS REINFORCED PLASTIC ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGRO 0, BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRA ITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED RENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEELIIRON A U 2 STAINLESS STEEL A U 3 POLYVIN 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 CLA W/FRP A U 8 100% 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 P MARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 6 3 VADOSE WELLS P S 4 ELECTA NIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 3 6 PRECISION P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNO P S 99 OTHER VL INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED (MO/YR) J:2.OFAOFMY WAS TANK FILLED WITH G ININERT MATERIAL? ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THEWZEDGE, IS TRUE AND CORRECT APPLICANT'S NAME (PRINTED & SIGNATURE) GATE LOCAL AGENCY USE ONLY COUNTY # JURISDICTION # AGENCY # FACILITY ID # 1616 � 137E] %TANKID* CURRENT LOCAL AGENCY FACILITY ID k APPROVED BY NAME PHONE k WITH AREA CODE Z. PERMIT NUMBER PERMIT APPROVAL DATE P RMIT EXPIRATION DATE CHECK 0 PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT k BY: FORM B (6-29-88) THIS FORM MUST 13E ACCOMPANIED TY A FACILITYISITE APPLICATION, FORM 'A', UNLESS A RRENT FORM `A' HAS BEEN FILED DATA PROCESSING COPY IQ 01 CD