BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORN WATER RESOURCES CONTROMOARD FORM 'B': UNDEIMROUND STORAGE TANK PROTRAM TANK TANK PERMIT APPLICATION INFORMATIONo • COMPLETE A SEPARATE FORM WITH THE FOLLOWING 1NFORMATION FOR EACH TANK. _- MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY LOS ONE ITEM ❑ 2 INTERIM PERMIT ❑q AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE B TANK REMOV D k7 FACILITY/SITE NAME WHERE TANK IS INSTALLED: / y L� ARM TANK-YES NO I. TANK DESCRIPTION �� LI COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK IDB B. MANUFACTURED BY: CTJ C. YEAR INSTALLED W' D. TANK CAPACITY IN GALLONS: D611 II. TANK C NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM u 7PC.A.S.# 2 LEADED 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑2 WASTE 99 OTHER(DESCRIBE IN ITEM D,BELOW) 0. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.R : III. TANK CONSTRUCTION MARK ONE ITEM ONLYIN BOK A,B,C,&D A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLEWALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER B. E] 1 STEEL/IRON 1:12 STAINLESS STEEL ❑3 FIBERGLASS E]4 STEEL CLAD W/FIBERGLSS REINFORCED PLASTIC MATERIAL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ Z ALUMINUM ❑8 IOW METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ I RUBBERUNED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PHENOLICLINING LINING ❑ 5 GLASS LINING ❑6 UNLINED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL7 ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ I POLYETHLENEWMP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 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 LA I SUCTION A U 2 PRESSURE A U 3 GRAVITY 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 TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A V 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5ALUMINUM A U 6CONCRETE A U 7STEELCLADW/FOP A U 8100%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 S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURETESTING P B 91 NONE P S 95 UNKNOWN P 6 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF SUBSTANCE REMAINING IN 3.WAS TANK FILLED WITH OALLONB INERT MATERIAL? ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME IPHINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY a COUNTY B JURISDICTION M AGENCY K FACILITY ID K EET � � TANK IDM LCURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE A WITH AREA CODE PEAYIT NUYBER !/�' PERMIT APPROVAL DATE PERYIT EKPIRATION DATE Z CHECK PERMITAMOUNT SURCHARGE AMT. FEE CODE RECEIPTI By:�/'�✓ FORMB(6-29-BB) THIS FORM MUST BE ACCOMP BY A FACILITYISITE APPLICATION, FORM 'A,UNLESS'a CURRENT FORMA' HASBEENFILED DATA PROCESSING COPY