BILLING - Laserfiche WebLink

Home Browse Search

STATE OPCALIFORNI* WATER RESOURCES CONTR•BOARD ^� FORM 'B' "UNDERGROUND STORAGE TANK PROGRAM an TANK TANK PERMIT APPLICATION INFORMATION yam " COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z' ' MARK ONLY r,LJI NEW PERMIT ❑ 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO I C ONE ITEM ',❑ 21NTERIMPERMIT ❑ 1 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVEDr0fl p CA3 FACILITY/SITE NAME WHERE TANK IS INSTALLED: S A7 Nf /—7 ❑ ARM TANK•YES NO n] I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—50SPECIFY /S37G CO A. OWNERS TANK IDX B. MANUFACTURED BY: G� C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 6) It. TANK C0f4TENTS IF(A.1).IS MARKED,COMPLETE ITEM C.IF(A.1).IS T MARKED,COMPLETE ITEM D. A• 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ / 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&CAS.8 C.A.S.X: Ill. TANK CONSTRUCTION MARKONEITEMONLYINSOXA B4O.&D A TYPE OF ❑ I DOUBLE WNM ❑ 3 SINGLE WALLED WITH EI(TFAIOR UNER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WAILED ❑A SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEEUIRON ❑2 STAINLESSSTEEL ❑3 FIBERGLASS ❑ 1 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL 5 CONCRETE 6 POLYVINYLCHLORIDE 7 ALUMINUM B 1OD%METHANOL COMPATIBLE FAP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C.INTERIOR - ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑3 EPDXY LINING ❑ 1 PHENOUCUNING LINING, ❑5 GLASS LINING ❑ 6 UNUNED ❑ 95 UNKNOWN ' '❑ ISUNINGl1ATEAMLCOMPATIBLEWITHIM%METML7 ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ I POLYETHLENEWMP ❑ 2 TARORASPIW.T ❑3 VINYLWRAP ❑ 1 FIBERGLASS REINFORCED PLASTIC PROTECTION -❑ 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 I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U-91 NONE A U 95 UNKNOWN A U 99 OTHER S. CONSTRUCTION A U 1 SINGLEWALLEDA U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U A FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U s ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 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 PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P % 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P B T PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF3.-WAS FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? E]YES E] NO DALLONB THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME LPRINTEO A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION Y nAGNCCY�B FACILITY ID 8 TANK ID 8 CURRENT LOCAL AGENCY FACILITY ID I APPROVED BT NAME PHONE E WITH AREA CODE PERMITNUMBER PERMIT APPROVAL DATE PERYIT EXPIRATION DATE CHECK PER MITAMOUNT SURC HARGE AMT. FEE CODE ECEIPTI by:01 w i • .. FORMS(6.29•B6) THIS FORM MUST BE ACCOMPANIFD RY A FArII ITY/UTP I dol i r.T.nu Chou IA. _