BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA# WATER RESOURCES CONTRO ARD UNDERGROUND STORAGE TANK PRO AMgo FORM `B':TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING I FORMATION FOR EACH TANK. J MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO E ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED' / ,f}C g� 7� ARM TANK-YES NO ❑ CA3 FACILITY/SITE NAME WHERE TANK IS INSTALLED: t' e2r- �� I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY B. MANUFACTURED BV: A. OWNERS TANK ID# j/ D G YEAR INSTALLED /L . TANK CAPACITY IN 1:411 11 S: N 11. T7n77:7 IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. B G. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL FUEL ❑ 2 PETROLEUM ❑ 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS UCT ❑ 4 OIL80 EMPTY [j?9955 UNKNOWN 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) ❑ LYJ ❑ U IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.It HAZARDOUS SUBSTANCE STORED&C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,k D FTANKF-] OUBLE WALLED ❑ 3 SINGLE WALLED WITH EXFERIOR LINER 5UNKNOWN 99 OTHER INGLE WALLED ❑ 4 SECONDARY CONTAINMENT TEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC ONCRETE ❑6 POLYVINYLCHLORIDE ❑7 AL INUM ❑ 8100%METHANOL COMPATIBLE FAP RONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑ 99 OTHER UBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 P NOLIC LINING C. INTERIOR ❑ 5 GLASS LINING ❑6 UNLINED 5 UNKNOWN LINING ❑ ISLINING MATERIAL COMPATIBLE WITH 100%METHANOL? E]YES NO 99 OTHER D.CORROSION ❑ 1 POLYETHLENEWRAP ❑ 2 TAR OR ASPHALT ❑ 3 -WRAP E]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 ;UA)5 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED-FRENCH A U 91 NONE A Z 5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U SALUMINUM ;s 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL 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 I VISUALCHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P 5 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3 wns TANK Hued WITH I. ESTIMATED DATE LAST USED IMO/YR) 2. ESTIMATED QUANTITY OF SUBSTANCE REMAINING IN INERT MATERIAL? OYES ❑ NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. DATE APPLICANT'S NAME(PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY InuIIS�I ----I��I� I�I TTISI TANK ID# FPERMITNUbSER JURISDICTION# AGEL�r✓ FACILITY ID# tt" o Lv `7 F67= �� APPROVED BY NAME PHONE M WITH AREA CODE NCY F C I I PERMIT APPROVAL DATE PERMIT EXPIRATION DATE -/? _�,n CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE EC # BY.. �J FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM `A',UNLESS A URRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY