BILLING 1986-1992 - Laserfiche WebLink

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STATE OF CALIFORNIP WATER RESOURCES CONTRftARD °-. FORM `BN: UNDERGROUND STORAGE TANK PROG AM ' TANK / TANK PERMIT APPLICATION INFORMATION • �o C/ COMPLETE A SEPARATE FORM WITH THE FOLLOWING I ORMATION FOR EACH TANK. - z IO 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CL MARK ONLY F-11 NEWPERMIT ❑ ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVE O J ) W FACILITY/SITE NAME WHERE TANK 18 INSTALLED: 6 I-96 FARM TANK-YES NO (� I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY( C,6— 7 CD i A. OWNERS TANK ION B. MANUFACTURED BY: 00 C.YEAR INSTALLED Yj D. TANK CAPACITY IN GALLONS: D O OO azzz II. TANK 96NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(At),IS NOT MARKED,COMPLETE ITEM D. A. Vi MOTOR VEHICLE FUEL ❑2 PETROLEUMC. E] 1 UNLEADED ❑ 2 LEADED 3 DIESEL F-13 CHEMICAL PRODUCT E] B.4 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 8 C.A.S.N C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,AD A TYPE OF ❑ 1 BLEWALLED F-13 SINGLE WALLED WITH EXTERIOR UNER ❑ 95 UNKNOWN SYSTEM LEWALLED ❑4 SECONDARYCONTAINMENT ❑ 99 OTHER 1 STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS OTHI CUO WIFIBERGLASS REINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUMMETHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED MEL ❑95 UNKNOWN ❑ I RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING YKNOWN LICUNING C. INTERIOR LINING ❑5 GLASS LINING ❑6 UNLINED ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NOER D. CORROSION ❑ I POLYETMLENE WRAP ❑2 TAR OR ASPHALT ❑ 9,ZWLWMP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION [D5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVE GROUND, U IF UNDERGROUND,BOTH IFAPPLICABLE A SYSTEM TYPE A 1 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 U 5 UNKNOWN A U 99 OTHER A U1 STEELARON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5ALUMINUM ACONCRETE A U 7STEELCLADW/FRP A U 8 10D%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A&,45 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. 5 P S 1 VISUAL CHECK P 8 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 6 4 ELECTRONIC MONITOR P 6 5 GROUNDWATER MONITORING WELLS 0 P S 6 PRECISION TESTING P 8 7 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 UST USED(MO/YR) 2.ESTIMATED QUANTITY OfOALLONB 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID N TANK ID N 0 71 CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE PERMITNUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECKN PERMIT AMOUNT SURCHARGE AMT. FEE CODE ECEIPTN BY: ly FORMB(629-aa) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A C'RRENT FORMA HASBEENFILED DATA PROCESSING COPY