BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORW WATER RESOURCES CONT L BOARD FORM 'B': UN RGROUND STORAGE TANK P GRAM TANK TANK PERMIT APPLICATION INFORMATION m COMPLETE A SEPARATE FORM WITH THE FOLLOWING INF TION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT E115"CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TAUK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑'6/TEMPORARY TANK CLOSURE ❑B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: a�D S. ve/-6a� FARM TANK-YES❑ NO O 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID If B. MANUFACTURED BY: (� C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: p pQ O II. TANK 904TENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.Y),IS NOT MARKED,COMPLETE ITEM D. IN CJ1 A. E51 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. C. ❑ 1 UNLEADED ❑ 2 LEADED DIESEL F-13 CHEMICAL PRODUCT ❑ 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 d C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1 DPbILEWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM EkfSIN ALLEG ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER Eg�' STEELARON ❑2 STAINLESS STEEL ❑3 RBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑810A METHANOL COMPATIBLE RIP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑2 NING F-] 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING ❑5 GLASS LINING 6 UNLINEDDLI ❑ 95 UNKNOWN ❑ ISUNING MATERIAL COMPATIBLE WITH ION METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 OR ASPHALT F-13 VINYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC ODIC PROTECTION ❑ 5 CATHPROTECTION 91 NONE 0 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 CTION 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 fr-qrLE7ALL3> A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A STEEL/IR A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 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 S IVISUALCHECK P S 2 INVENTORY RECONCILIATION P S 3VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S ON P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH GALLONS 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. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANID# 3 / � iK a / C ENT LOCAL AGENCY FACILITY ID# APPRp YNAME )PHOaNE#WITH AREA CODE R1 PoA� 4Z PERMIT PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECKN PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# I BY: FORM B(6-29-ee) THIS FORM MUST BE ACCOMPANIED BY A FAC L I /SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED G DATA PROCESSING COPY