BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORIO WATER RESOURCESCONTFf&OARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION , COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY/�/ ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM L ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMO FACILITY/SITE NAME WHERE TANK IS INSTALLED: 3 3/a fL 4- ,33 FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK I B. MANUFACTURED BY: C6) u4 C.YEAR INSTALLED A✓ D. TANK CAPACITY IN GALLON O CIC) 11. TANK CqWENTS IF(AL1),IS MARKED,COMPLETE ITEM C.IF(AL1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. �{'j C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ICAL ET FUEL 6 ION GAS ❑5 HAZARDOUS DOUS PRODUCT ❑80 EMPTY 95 UNKNOWN 2 WASTE C/ ❑7 METHANOL ❑99JOTHER(DESCRIBE ITEM DTBELOW) 4 D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF �j- HAZARDOUS SUBSTANCE STORED&C.A.S.# 1. �' C.A.S. All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,a D A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXIFRIOR LINER 95 UNKNOWN SYSTE �� ❑2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER A ❑1 STEELARON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK tS ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 A UM ❑8100%METHANOL COMPATIBLE FRP MATEERl ❑9 BRONZE ❑10 GALVANIZED STEEL I--I UNKNOWN E] 99 OTHER ❑ 1 RUBBER LINED 2 ALKYD LINING s..l 13 EPDXY LINING ❑4 PHENO CLINING C. INTER( R`d ^„//pT LINING ❑5 GLASS LINING ❑6 UNLINED / NKNOWN IS LINING MATERIAL COMPATIBLE WITH IDB%METH OL? 7 YES NO ❑99 OTHER D.CORR 0 I POLYEIHLENEWRAP ❑2 TAR OR ASPHALT ❑3 VINY P ❑4 FlBERGLASS REINFORCED PLASTIC PROTE N ❑5 CATHODIC PROTECTION ❑91 NONE 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 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE IPVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A JA,,6 CONCRETE A U 7 STEELCLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER FVI. LEAK DETECS I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS S 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE- 95 UNKNOWN P S 99 OTHER FORMATION ON TANK PERMANENTLY CLOSED IN PLACE L ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH /V I SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? E]YES ❑ NO THIS FORM HAS§EEN 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 LINTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 39 I I 1�1 = V'AoIA111121 Loo 03 CWWNT LOCAL AGENCY FACIL17YID# A-01IROVED BY NAff E PHONE#WITH AREA CODE %PkhMIT NUMBER PERMITAPPRO ALD TE PERMIT EXP( ION DATE 177 CHECK# PERMITAMO NT SURCHARGE IT. FEE CODERECEIPT# BY: FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORKWUNWACURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY