BILLING_1988-1999 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORN10 WATER RESOURCES CONT OARD FORM V: UNDERGROUND STORAGE TANK PR RAM ado TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT V5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY C TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT >r ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED /J FACILITY/SITE NAME WHERE TANK IS INSTALLED• Z W -'j, FARM TANK-VES NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN- SO SPECIFY ,O A. OWNERS TANK ID# Z B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(a1),IS MARKED,COMPLETE ITEM C.IF(A.7),IS NOT MARKED,COMPLETE ITEM D. W EIFNOT TOR VEHICLE FUEL ❑ 2 PETROLEUM B. C Lltfl UNLEADED ❑2 LEADED ❑3 DIESEL EMICAL PRODUCT ❑ 4 OIL PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑ 6 AVIATION GAS ZARDOUS ❑ 80EMPTY ❑ 95UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) TOR VEHICLE FUEL,ENTER NAME OFUS SUBSTANCE STORED 8 C.A.S.# , 1 C.A.S.#: IMJ xlII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A TYPE OF ❑ 1 DOUBLEWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER SYSTEM ❑ 95 UNKNOWN T�2 SINGLE WALLED ❑ q SECONDARY CONTAINMENT ❑ gg OTHER u B.TANK I STEELPRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING 6 UNLINED F-1 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH I00%METHANOL'+ ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ I POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION [:]91 NONE ❑ �95 UNKNOWN ❑gg OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY B. CONSTRUCTION A 1 SINGLE WALLED A A U 99 OTHER U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A OU 1 STEEL/IRON A U 99 OTHER A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE IPVC) A U 4 FIBERGLASS PIPE { C. MATERIAL A U 5 ALUMINUM A U C 6 CONCRETE I A U 7 STEEL CLAD W/FRP A U S 100%METHANOL COMPATIBLE FRP 1ILL ✓J I 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 5 1 VISUAL CHECK S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 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 1. ESTIMATED DATEL(AS�T SED(MO/VR) 2. ESTIMATED QUANTITY OF W �. SUBSTANCE REMAJNIIyG 3. Wq5 TANK EI LLED WITH per) GALLONS INERT MATERIALS 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 C�(OOU'NNT"YY## JURISDICTION# AGENCY# x-4-1 C-) D FACILITY # TANK ID# q S- CUFF' o[<'Ib F2- ENT LOCAL AGENCY FACILITY ID k AP PR E BY NA E,{T� PHONE p WITH AREA CODE PERMIT NUMBER PERMITAPPROVALDATE E IT EXPIRATION DATE \\ CHECK# PERMIT AMOUNT\\ SURCHARGE AMT. FEE CODE CEIPTp BY: FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY